Healthcare Provider Details

I. General information

NPI: 1104155472
Provider Name (Legal Business Name): LISA M SANDRE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W THOMAS RD SUITE 130
PHOENIX AZ
85013-4405
US

IV. Provider business mailing address

124 W THOMAS RD SUITE 130
PHOENIX AZ
85013-4405
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-4185
  • Fax: 602-294-5943
Mailing address:
  • Phone: 602-406-4185
  • Fax: 602-294-5943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberDA6450
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberDA6450
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: