Basic Information
Provider Information | |||||||||
NPI: | 1902339641 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CODY | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | ELLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AGPCNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 709 E BROAD ST | ||||||||
Address2: |   | ||||||||
City: | GADSDEN | ||||||||
State: | AL | ||||||||
PostalCode: | 359032452 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2565476311 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1005 W CIRCLE ST | ||||||||
Address2: |   | ||||||||
City: | AVON PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 338252928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8634535500 | ||||||||
FaxNumber: | 8634535566 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2017 | ||||||||
LastUpdateDate: | 11/21/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 2014029444 | AL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 2014029444 | AL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.