Provider Demographics
NPI:1093506701
Name:AGAZIE, MSN, APRN, PMHNP-BC, CMSRN, SANDRA I
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:I
Last Name:AGAZIE, MSN, APRN, PMHNP-BC, CMSRN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7586 OLDHAM LN
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3595
Mailing Address - Country:US
Mailing Address - Phone:404-736-4343
Mailing Address - Fax:844-270-7142
Practice Address - Street 1:115 BRADFORD SQ STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-1962
Practice Address - Country:US
Practice Address - Phone:404-736-4343
Practice Address - Fax:844-870-7142
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170538363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty