MEDICARE: MARYLOU SANDOVAL IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)	L-29114	AZ

General Provider Information

NPI Number	:	1073972915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYLOU SANDOVAL IBCLC

Provider Business Mailing Address
First Line	:	3536 W SAN JUAN AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85019-4514
Country	:	US
Telephone Number	:	623-980-0347
Fax Number	:

Provider Business Practice Location Address
First Line	:	3536 W SAN JUAN AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85019-4514
Country	:	US
Telephone Number	:	623-980-0347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2016
Last Update Date	:	02/22/2016

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