Basic Information
Provider Information | |||||||||
NPI: | 1538475421 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANDIFORD | ||||||||
FirstName: | JANICE | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1835 SAVOY DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303411072 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709815431 | ||||||||
FaxNumber: | 7704952307 | ||||||||
Practice Location | |||||||||
Address1: | 5700 HILLANDALE DR STE 250 | ||||||||
Address2: |   | ||||||||
City: | LITHONIA | ||||||||
State: | GA | ||||||||
PostalCode: | 300584120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709815431 | ||||||||
FaxNumber: | 7709815515 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2010 | ||||||||
LastUpdateDate: | 08/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN120356 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 003101232C | 05 | GA |   | MEDICAID | 202I503406 | 01 | GA | MEDICARE PTAN | OTHER |