Provider Demographics
NPI:1740307941
Name:STAFFORD, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:STAFFORD
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 1:768 WILLIE JARVIS RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-5645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 SPARTA ST
Practice Address - Street 2:TENN DEPT OF HEALTH
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1301
Practice Address - Country:US
Practice Address - Phone:931-473-8468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN84392163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse