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General NPI Number Information
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NPI Number | 1356011514
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Entity Type | Individual
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Provider Name | ITZEL SANDOVAL-REYNOSO PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/17/2021
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Last Update Date | 11/21/2025
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Provider Practice Location Address
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Address Line | 380 PINE LEAF DR
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-1462
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Country | US
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Telephone | 904-707-3147
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Fax |
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Provider Business Mailing Address
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Address Line | 380 PINE LEAF DR
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-1462
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Country | US
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Telephone | 904-707-3147
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9115077
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9115077
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License Number State | FL
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