Provider Demographics
NPI:1134779713
Name:GADDIS, SANDRA JEAN
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:GADDIS
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 1:272 W BADGER LN
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-8763
Mailing Address - Country:US
Mailing Address - Phone:360-545-7293
Mailing Address - Fax:
Practice Address - Street 1:272 W BADGER LN
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-8763
Practice Address - Country:US
Practice Address - Phone:360-545-7293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider