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General NPI Number Information
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NPI Number | 1093224438
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Entity Type | Individual
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Provider Name | SARAH LYNETTE SANDOVAL NP
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Gender | Female
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Dates
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Enumeration Date | 09/28/2017
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Last Update Date | 09/03/2019
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Provider Practice Location Address
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Address Line | 509 HAMACHER ST STE 103
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City | WATERLOO
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State | IL
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Zip | 62298-1592
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Country | US
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Telephone | 618-939-2273
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Fax | 618-939-0245
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Provider Business Mailing Address
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Address Line | 220 NORMA AVE
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City | WATERLOO
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State | IL
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Zip | 62298-1528
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 041427444
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 2012020830
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209016207
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License Number State | IL
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