Provider Demographics
NPI:1720103047
Name:SANFORD, SALLY JO (APRN)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:JO
Last Name:SANFORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 LITTLE RD NE
Mailing Address - Street 2:
Mailing Address - City:RESACA
Mailing Address - State:GA
Mailing Address - Zip Code:30735-6522
Mailing Address - Country:US
Mailing Address - Phone:706-625-7376
Mailing Address - Fax:770-773-9803
Practice Address - Street 1:14 LEGACY WAY STE B
Practice Address - Street 2:
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-2455
Practice Address - Country:US
Practice Address - Phone:770-773-9902
Practice Address - Fax:770-773-9803
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN072580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily