MEDICARE: CAROLINA SANDOVAL PNP

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	363LP0200X	Pediatric Nurse Practitioner	502270	CA

General Provider Information

NPI Number	:	1477681260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLINA SANDOVAL PNP

Provider Business Mailing Address
First Line	:	1501A S BON VIEW AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-4408
Country	:	US
Telephone Number	:	909-673-9125
Fax Number	:	909-673-1676

Provider Business Practice Location Address
First Line	:	1501A S BON VIEW AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-4408
Country	:	US
Telephone Number	:	909-673-9125
Fax Number	:	909-673-1676

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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