Provider Demographics
NPI:1578966065
Name:SANDIFER, MELENA (CPM, LM)
Entity Type:Individual
Prefix:
First Name:MELENA
Middle Name:
Last Name:SANDIFER
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:VAN
Mailing Address - State:TX
Mailing Address - Zip Code:75790-0351
Mailing Address - Country:US
Mailing Address - Phone:903-316-8337
Mailing Address - Fax:903-280-7686
Practice Address - Street 1:215 S VINE AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-7143
Practice Address - Country:US
Practice Address - Phone:903-316-8337
Practice Address - Fax:903-280-7686
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99218176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife