Healthcare Provider Details

I. General information

NPI: 1275155764
Provider Name (Legal Business Name): ARIANA SANDOVAL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 07/04/2023
Certification Date: 07/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6447 CERMAK RD
BERWYN IL
60402-2311
US

IV. Provider business mailing address

153 CEDARWOOD AVE
BOLINGBROOK IL
60440-3005
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax:
Mailing address:
  • Phone: 708-769-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.020936
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.020936
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: