Provider Demographics
NPI:1124395272
Name:SANDIDGE, MARY KAE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KAE
Last Name:SANDIDGE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 NW 80TH PLACE
Mailing Address - Street 2:
Mailing Address - City:RAIFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32083
Mailing Address - Country:US
Mailing Address - Phone:941-232-6513
Mailing Address - Fax:
Practice Address - Street 1:4348 SOUTHPOINT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0903
Practice Address - Country:US
Practice Address - Phone:904-281-1915
Practice Address - Fax:904-281-1119
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1853212363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004575500Medicaid
FV107Medicare PIN