Provider Demographics
NPI:1306390430
Name:DEFALCO, SANDRA (FNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DEFALCO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 IVY CREEK FRD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-8146
Mailing Address - Country:US
Mailing Address - Phone:631-741-9504
Mailing Address - Fax:
Practice Address - Street 1:4724 CHARLOTTE HWY
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-8095
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCDEFA-B904U1363LF0000X
NC5008816363LF0000X
SC20227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily