Basic Information
| Provider Information | |||||||||
| NPI: | 1427066455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLAND | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PROVINES | ||||||||
| OtherFirstName: | SANDRA | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5208 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393025208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039485 | ||||||||
| FaxNumber: | 6017039283 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 N. LORETTO RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706992229 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 3016943 | KY | N | Other Service Providers | Midwife | 176B00000X | 899566 | MS | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 420000052 | 01 | RAILROAD MEDICARE | OTHER | 238524 | 01 | HEALTHLINK | OTHER | 7100780290 | 05 | KY | MEDICAID |