Provider Demographics
NPI:1174768485
Name:DENNIS, SANDRA (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DENNIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38025-0688
Mailing Address - Country:US
Mailing Address - Phone:901-476-9339
Mailing Address - Fax:
Practice Address - Street 1:1999 HIGHWAY 51 S
Practice Address - Street 2:SUITE A
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3630
Practice Address - Country:US
Practice Address - Phone:901-476-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN13637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ003781Medicaid
AR214846758Medicaid
MS09253832Medicaid