Provider Demographics
NPI:1841672177
Name:SANDEFUR, SARAH JENE
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:JENE
Last Name:SANDEFUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:JENE
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:879 E ASHWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-1412
Mailing Address - Country:US
Mailing Address - Phone:513-439-3669
Mailing Address - Fax:
Practice Address - Street 1:879 E ASHWOOD LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-1412
Practice Address - Country:US
Practice Address - Phone:907-373-2149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK962560225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist