Provider Demographics
NPI:1124782024
Name:SOUTHERLAND, SANDRA MARIE
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:MARIE
Last Name:SOUTHERLAND
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 1:219 BLACKBERRY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5648
Mailing Address - Country:US
Mailing Address - Phone:301-768-1515
Mailing Address - Fax:
Practice Address - Street 1:2038 34TH ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2416
Practice Address - Country:US
Practice Address - Phone:202-584-4842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant