MEDICARE: SHEARITA SANDOVAL ANP- BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	2014043293	MO

General Provider Information

NPI Number	:	1053705392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEARITA SANDOVAL ANP- BC

Provider Business Mailing Address
First Line	:	5471 DR. MARTIN LUTHER KING DR.
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-4265
Country	:	US
Telephone Number	:	314-367-5820
Fax Number	:	314-367-6326

Provider Business Practice Location Address
First Line	:	3113 MAGNOLIA AVE
Second Line	:	APT 2E
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-1271
Country	:	US
Telephone Number	:	314-749-6708
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2015
Last Update Date	:	09/05/2025

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