Provider Demographics
NPI:1871167734
Name:SANDOVAL, MICHELLE DIANE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANE
Last Name:SANDOVAL
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 1:4819 S DRAGOON DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-6043
Mailing Address - Country:US
Mailing Address - Phone:480-861-8214
Mailing Address - Fax:
Practice Address - Street 1:14614 N KIERLAND BLVD STE N230
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2747
Practice Address - Country:US
Practice Address - Phone:480-719-3271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN103623163WC3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC3500XNursing Service ProvidersRegistered NurseCardiac Rehabilitation