Provider Demographics
NPI:1114415288
Name:JOHN, SALLY (NP-FAMILY)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:NP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 TALBOT LN
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-3221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:289 TALBOT LN
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-3221
Practice Address - Country:US
Practice Address - Phone:469-682-1955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily