Healthcare Provider Details

I. General information

NPI: 1407492929
Provider Name (Legal Business Name): MELANIE FLEUR SANDOVAL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 LAKEVIEW AVE
PUEBLO CO
81004-3508
US

IV. Provider business mailing address

PO BOX 800022
KANSAS CITY MO
64180-0022
US

V. Phone/Fax

Practice location:
  • Phone: 719-557-3660
  • Fax: 719-557-3690
Mailing address:
  • Phone: 800-953-0104
  • Fax: 303-765-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0995300-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0178632
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0178632
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0178632
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: