Basic Information
| Provider Information | |||||||||
| NPI: | 1356825251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GADDIS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 APPLEWOOD DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705033 | ||||||||
| FaxNumber: | 7062705111 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 N 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307052416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2018 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN042000 | GA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.