Provider Demographics
NPI:1629686027
Name:PERCY-SMITH, SANDRA DENISE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DENISE
Last Name:PERCY-SMITH
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 1:3601 INVERRARY DR APT A301
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5934
Mailing Address - Country:US
Mailing Address - Phone:754-368-0069
Mailing Address - Fax:
Practice Address - Street 1:2309 E 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-6345
Practice Address - Country:US
Practice Address - Phone:850-747-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9454129163W00000X
FL11012976363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse