Provider Demographics
NPI:1619161270
Name:DOUGLAS, SANDRA KAY
Entity Type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:KAY
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4027
Mailing Address - Country:US
Mailing Address - Phone:919-775-2001
Mailing Address - Fax:919-775-1053
Practice Address - Street 1:106 PARK AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4027
Practice Address - Country:US
Practice Address - Phone:919-775-2001
Practice Address - Fax:919-775-1053
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFM01520332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795301Medicaid