Provider Demographics
NPI:1699933309
Name:FARRELLY, SANDRA R (RN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:R
Last Name:FARRELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 S TRADE ST
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5772
Mailing Address - Country:US
Mailing Address - Phone:704-841-8882
Mailing Address - Fax:
Practice Address - Street 1:196 S TRADE ST
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5772
Practice Address - Country:US
Practice Address - Phone:704-841-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75437163W00000X
NC5004023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004174Medicaid
SCNP1263Medicaid
SCNP1263Medicaid