Provider Demographics
NPI:1427066455
Name:POLAND, SANDRA J (CNM)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:J
Last Name:POLAND
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:J
Other - Last Name:PROVINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5208
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5208
Mailing Address - Country:US
Mailing Address - Phone:601-703-9485
Mailing Address - Fax:601-703-9283
Practice Address - Street 1:330 N. LORETTO RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033
Practice Address - Country:US
Practice Address - Phone:270-699-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016943176B00000X
MS899566176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
420000052OtherRAILROAD MEDICARE
238524OtherHEALTHLINK
KY7100780290Medicaid
IL294490002Medicare PIN