Provider Demographics
NPI:1093224438
Name:SANDOVAL, SARAH LYNETTE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:LYNETTE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:SARAH
Other - Middle Name:LYNETTE
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:220 NORMA AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 HAMACHER ST STE 103
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-2273
Practice Address - Fax:618-939-0245
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041427444163W00000X
MO2012020830207QA0505X
IL209016207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1649315219Medicaid