Healthcare Provider Details

I. General information

NPI: 1376334433
Provider Name (Legal Business Name): AMANDA LISA SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 MEDLEY CT
VINE GROVE KY
40175-8421
US

IV. Provider business mailing address

518 BALMORAL RD
ELIZABETHTOWN KY
42701-2211
US

V. Phone/Fax

Practice location:
  • Phone: 270-352-1133
  • Fax:
Mailing address:
  • Phone: 270-304-4989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number298870
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: