Healthcare Provider Details

I. General information

NPI: 1093224438
Provider Name (Legal Business Name): SARAH LYNETTE SANDOVAL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAH LYNETTE YATES NP

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 HAMACHER ST STE 103
WATERLOO IL
62298-1592
US

IV. Provider business mailing address

220 NORMA AVE
WATERLOO IL
62298-1528
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-2273
  • Fax: 618-939-0245
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041427444
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number2012020830
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209016207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: