Provider Demographics
NPI:1437580255
Name:ARNOLD, SALLY LEE (APRN)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:LEE
Last Name:ARNOLD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 BRISTOL INDUSTRIAL WAY STE 109
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-1775
Mailing Address - Country:US
Mailing Address - Phone:478-550-5882
Mailing Address - Fax:
Practice Address - Street 1:5012 BRISTOL INDUSTRIAL WAY STE 109
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1775
Practice Address - Country:US
Practice Address - Phone:478-550-5882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN169765163W00000X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003149740AMedicaid