Healthcare Provider Details

I. General information

NPI: 1932019189
Provider Name (Legal Business Name): MIRANDA KAYE SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

130 ASHLEY LN
CORRALES NM
87048-8922
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-5053
  • Fax:
Mailing address:
  • Phone: 505-414-5053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number66410
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: