Provider Demographics
NPI:1225188196
Name:SANFORD, LISA ANN (MSN FNP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:SANFORD
Suffix:
Gender:F
Credentials:MSN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 TALLY HO DR
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-8451
Mailing Address - Country:US
Mailing Address - Phone:919-965-4459
Mailing Address - Fax:
Practice Address - Street 1:3305 SUNGATE BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2871
Practice Address - Country:US
Practice Address - Phone:919-212-0129
Practice Address - Fax:919-255-1540
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC105289363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7000247Medicaid