Healthcare Provider Details

I. General information

NPI: 1376765685
Provider Name (Legal Business Name): MARICELA SANDOVAL APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5758 S MARYLAND AVE
CHICAGO IL
60637-1426
US

IV. Provider business mailing address

6137 S MAYFIELD AVE
CHICAGO IL
60638-4405
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax: 773-834-7068
Mailing address:
  • Phone: 773-702-1000
  • Fax: 773-834-7068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: