Healthcare Provider Details

I. General information

NPI: 1114821501
Provider Name (Legal Business Name): SANDRA NMESOMA OSUALA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5341 W LA SALLE ST
LAVEEN AZ
85339-2471
US

IV. Provider business mailing address

5341 W LA SALLE ST
LAVEEN AZ
85339-2471
US

V. Phone/Fax

Practice location:
  • Phone: 602-653-6308
  • Fax:
Mailing address:
  • Phone: 602-653-6308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberALH20388
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: