Provider Demographics
NPI:1477660975
Name:OSWALT, SANDRA FAYE (CFNP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:FAYE
Last Name:OSWALT
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:EUPORA
Mailing Address - State:MS
Mailing Address - Zip Code:39744-4018
Mailing Address - Country:US
Mailing Address - Phone:662-258-9400
Mailing Address - Fax:662-258-9433
Practice Address - Street 1:70 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-4018
Practice Address - Country:US
Practice Address - Phone:662-258-9400
Practice Address - Fax:662-258-9433
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR605859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07251213Medicaid
S18701Medicare UPIN
MS07251213Medicaid