Healthcare Provider Details

I. General information

NPI: 1013996180
Provider Name (Legal Business Name): CORIE LYNN SANDALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9230 SKY ISLAND DR E
BONNEY LAKE WA
98391-7385
US

IV. Provider business mailing address

9230 SKY ISLAND DR E
BONNEY LAKE WA
98391-7385
US

V. Phone/Fax

Practice location:
  • Phone: 253-750-6000
  • Fax: 253-750-6100
Mailing address:
  • Phone: 253-750-6000
  • Fax: 253-750-6100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00045674
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: