Provider Demographics
NPI:1548264047
Name:DUBOSE, SANDRA ELAINE (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ELAINE
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:JONES
Other - Last Name:DUBOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 740015
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0015
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:1631 GORDON HWY STE 17A
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2229
Practice Address - Country:US
Practice Address - Phone:706-230-7006
Practice Address - Fax:762-257-7442
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC129363LF0000X
GARN103532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0278Medicaid
GA000829595AMedicaid
GA000829595AMedicaid
GAS99358Medicare UPIN