Provider Demographics
NPI:1265067201
Name:PURK, SANDRA (ADMINISTRATOR)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PURK
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 RACHEL BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34607-2532
Mailing Address - Country:US
Mailing Address - Phone:352-405-1234
Mailing Address - Fax:352-388-1924
Practice Address - Street 1:725 DESOTO AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2813
Practice Address - Country:US
Practice Address - Phone:352-405-1234
Practice Address - Fax:352-388-1924
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30212059374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide