Provider Demographics
NPI:1649956244
Name:SANFORD, KELLIE AMBER (CNA2)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:AMBER
Last Name:SANFORD
Suffix:
Gender:F
Credentials:CNA2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 NEBRASKA AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5700
Mailing Address - Country:US
Mailing Address - Phone:541-956-4943
Mailing Address - Fax:
Practice Address - Street 1:10 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7445
Practice Address - Country:US
Practice Address - Phone:541-772-0127
Practice Address - Fax:541-772-0966
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health