Healthcare Provider Details

I. General information

NPI: 1568762011
Provider Name (Legal Business Name): LORETTA SANDOVAL RN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORETTA GOREVIN RN

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 E BARNETT RD STE 102
MEDFORD OR
97504-8672
US

IV. Provider business mailing address

3617 S PACIFIC HWY
MEDFORD OR
97501-8957
US

V. Phone/Fax

Practice location:
  • Phone: 541-500-4747
  • Fax: 866-267-6644
Mailing address:
  • Phone: 541-535-6239
  • Fax: 541-512-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201042847RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number201250116NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: