Healthcare Provider Details

I. General information

NPI: 1164357760
Provider Name (Legal Business Name): KIMBERLY LYANNE SANDOVAL FNP-C, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 W BEVERLY LN
GLENDALE AZ
85306-1800
US

IV. Provider business mailing address

5810 W BEVERLY LN
GLENDALE AZ
85306-1800
US

V. Phone/Fax

Practice location:
  • Phone: 480-792-6024
  • Fax: 480-257-1992
Mailing address:
  • Phone: 480-792-6024
  • Fax: 480-257-1992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number230115
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: