Provider Demographics
NPI:1386946192
Name:LOTT, SANDRA PETERSON (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:PETERSON
Last Name:LOTT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1847 SIMPSON HIGHWAY 149
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-3439
Mailing Address - Country:US
Mailing Address - Phone:601-675-7142
Mailing Address - Fax:601-675-7143
Practice Address - Street 1:1847 SIMPSON HIGHWAY 149
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114-3439
Practice Address - Country:US
Practice Address - Phone:601-675-7142
Practice Address - Fax:601-675-7143
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09832569Medicaid
MS302I505369Medicare PIN