Provider Demographics
NPI:1457603334
Name:SELF, SANDRA (RN BSN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W END AVE
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-1725
Mailing Address - Country:US
Mailing Address - Phone:615-446-2839
Mailing Address - Fax:
Practice Address - Street 1:301 W END AVE
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-1725
Practice Address - Country:US
Practice Address - Phone:615-446-2839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000084424163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse