Healthcare Provider Details

I. General information

NPI: 1912702408
Provider Name (Legal Business Name): SHANNON SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 MENAUL BLVD NE
ALBUQUERQUE NM
87112-2435
US

IV. Provider business mailing address

300 MENAUL BLVD NW STE A
ALBUQUERQUE NM
87107-1347
US

V. Phone/Fax

Practice location:
  • Phone: 525-526-3649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: