Provider Demographics
NPI:1871134312
Name:SANFORD, BENN (MSN AGNP-C)
Entity type:Individual
Prefix:
First Name:BENN
Middle Name:
Last Name:SANFORD
Suffix:
Gender:M
Credentials:MSN AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3570 COLLEGE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4679
Mailing Address - Country:US
Mailing Address - Phone:409-839-3118
Mailing Address - Fax:
Practice Address - Street 1:2929 CALDER ST STE 100
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1841
Practice Address - Country:US
Practice Address - Phone:409-839-3118
Practice Address - Fax:409-654-6921
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143362363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology