Provider Demographics
NPI:1205030335
Name:BRANSON, SANDY MICHELE (APN)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:MICHELE
Last Name:BRANSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1006
Mailing Address - Street 2:
Mailing Address - City:WEST FORK
Mailing Address - State:AR
Mailing Address - Zip Code:72774-1006
Mailing Address - Country:US
Mailing Address - Phone:479-839-2670
Mailing Address - Fax:479-294-6067
Practice Address - Street 1:425-A N. CENTENNIAL
Practice Address - Street 2:
Practice Address - City:WEST FORK
Practice Address - State:AR
Practice Address - Zip Code:72774-1006
Practice Address - Country:US
Practice Address - Phone:479-839-2670
Practice Address - Fax:479-294-6067
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA02935363L00000X
ARR66717163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G077Medicare UPIN