Provider Demographics
NPI:1326511031
Name:SANFORD, ASHLEY DUEITT (CNP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DUEITT
Last Name:SANFORD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:DUEITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-705-2897
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-579-3376
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902714363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05857553Medicaid