Provider Demographics
NPI:1134231236
Name:ARMISTEAD, SALLY MACDONALD (FNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:MACDONALD
Last Name:ARMISTEAD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:MACDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2140 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5180
Mailing Address - Country:US
Mailing Address - Phone:904-213-0600
Mailing Address - Fax:904-213-0652
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-213-0600
Practice Address - Fax:904-213-0652
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000560363L00000X
FL9263604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004183448Medicaid
CT500000499Medicare ID - Type Unspecified
CTP15238Medicare UPIN