Provider Demographics
NPI:1417916172
Name:SANDY, FEDDY (NP)
Entity Type:Individual
Prefix:
First Name:FEDDY
Middle Name:
Last Name:SANDY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16360 TEMPLE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-3008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 W AVENUE A
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-3019
Practice Address - Country:US
Practice Address - Phone:561-992-4888
Practice Address - Fax:561-992-4888
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2919552363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303634100Medicaid
FL303634100Medicaid
FLE5757ZMedicare ID - Type Unspecified