Healthcare Provider Details

I. General information

NPI: 1679404487
Provider Name (Legal Business Name): SANDY M WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42461 W CAPISTRANO DR
MARICOPA AZ
85138-4399
US

IV. Provider business mailing address

42461 W CAPISTRANO DR
MARICOPA AZ
85138-4399
US

V. Phone/Fax

Practice location:
  • Phone: 909-480-9450
  • Fax:
Mailing address:
  • Phone: 909-480-9450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number30605
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: