Healthcare Provider Details

I. General information

NPI: 1760829543
Provider Name (Legal Business Name): MARY MADRIGAL SANDOVAL RN, PHN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 08/29/2020
Certification Date: 08/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 DONNA WAY
SAN JACINTO CA
92583-5517
US

IV. Provider business mailing address

11980 MOUNT VERNON AVE
GRAND TERRACE CA
92313-5172
US

V. Phone/Fax

Practice location:
  • Phone: 951-654-0803
  • Fax: 951-654-3917
Mailing address:
  • Phone: 909-864-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number531242
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: