Provider Demographics
NPI:1720127145
Name:JARVIS, SANDRA LEE (NP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:JARVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 TOWNCENTER DR STE 810
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9376
Mailing Address - Country:US
Mailing Address - Phone:980-533-0993
Mailing Address - Fax:
Practice Address - Street 1:6255 TOWNCENTER DR STE 810
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9376
Practice Address - Country:US
Practice Address - Phone:980-533-0993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-00468363LP0200X
NC200017363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC70003712Medicaid
SCNP3666Medicaid
NC70003712Medicaid