Healthcare Provider Details

I. General information

NPI: 1871167734
Provider Name (Legal Business Name): MICHELLE DIANE SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2021
Last Update Date: 05/16/2021
Certification Date: 05/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14614 N KIERLAND BLVD STE N230
SCOTTSDALE AZ
85254-2747
US

IV. Provider business mailing address

4819 S DRAGOON DR
CHANDLER AZ
85249-6043
US

V. Phone/Fax

Practice location:
  • Phone: 480-719-3271
  • Fax:
Mailing address:
  • Phone: 480-861-8214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC3500X
TaxonomyCardiac Rehabilitation Registered Nurse
License NumberRN103623
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: