Provider Demographics
NPI:1851379671
Name:EADDY, SANDRA J (CRNA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:EADDY
Suffix:
Gender:F
Credentials:CRNA
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 2757
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20195
Mailing Address - Country:US
Mailing Address - Phone:703-471-0919
Mailing Address - Fax:703-742-9081
Practice Address - Street 1:1850 TOWN CENTER PARKWAY
Practice Address - Street 2:RESTON HOSPITAL CENTER
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-471-0919
Practice Address - Fax:703-742-9081
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024000023163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010123151Medicaid