Provider Demographics
NPI:1629338496
Name:DAVIS, SANDRA
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 W 129TH ST APT GB
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-2271
Mailing Address - Country:US
Mailing Address - Phone:212-658-0638
Mailing Address - Fax:
Practice Address - Street 1:55 W 129TH ST
Practice Address - Street 2:APT. GB
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-2270
Practice Address - Country:US
Practice Address - Phone:646-559-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY711420961174400000X
NY1032049161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist