Provider Demographics
NPI:1114660859
Name:KING, SANDRA DENICE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DENICE
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76040 HARLEY CT
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-0613
Mailing Address - Country:US
Mailing Address - Phone:904-624-3072
Mailing Address - Fax:
Practice Address - Street 1:76040 HARLEY CT
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-0613
Practice Address - Country:US
Practice Address - Phone:904-248-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services