Provider Demographics
NPI:1982029575
Name:SANDFORD, OPAL
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:
Last Name:SANDFORD
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 1:100 HILLSIDE DR
Mailing Address - Street 2:APT B9
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-1357
Mailing Address - Country:US
Mailing Address - Phone:347-224-0791
Mailing Address - Fax:
Practice Address - Street 1:100 HILLSIDE DR
Practice Address - Street 2:APT B9
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-1357
Practice Address - Country:US
Practice Address - Phone:347-224-0791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307692164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse