Provider Demographics
NPI:1174517668
Name:JAFARI, SALLY DALE G (CRNP)
Entity type:Individual
Prefix:MRS
First Name:SALLY DALE
Middle Name:G
Last Name:JAFARI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:DALE
Other - Middle Name:G
Other - Last Name:REDDISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:403 PURDY ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-4059
Mailing Address - Country:US
Mailing Address - Phone:410-822-7040
Mailing Address - Fax:410-822-7056
Practice Address - Street 1:403 PURDY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-4059
Practice Address - Country:US
Practice Address - Phone:410-822-7040
Practice Address - Fax:410-822-7056
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR069947363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD130003200Medicaid
MD287111400Medicaid
DE000969542Medicaid
MD130003200Medicaid
DE000969542Medicaid