Provider Demographics
NPI:1104398833
Name:SANFORD, JESSICA MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:SANFORD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MAIRE
Other - Last Name:BOLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6557 STONELAKE WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-8160
Mailing Address - Country:US
Mailing Address - Phone:513-828-1578
Mailing Address - Fax:
Practice Address - Street 1:11500 NORTHLAKE DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-1650
Practice Address - Country:US
Practice Address - Phone:513-742-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2023-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008628A363LF0000X, 363LA2200X
OHCNP.020779363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.020779OtherLICENSE