Provider Demographics
NPI:1366171993
Name:LASSITER, SANDRA DENISE
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:DENISE
Last Name:LASSITER
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 1:1812 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-2271
Mailing Address - Country:US
Mailing Address - Phone:919-384-5758
Mailing Address - Fax:
Practice Address - Street 1:1812 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-2271
Practice Address - Country:US
Practice Address - Phone:919-384-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X, 251S00000X, 261Q00000X
NC2022-2799-01175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center