Provider Demographics
NPI:1194828079
Name:FAVORITE, SANDRA (CNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:FAVORITE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:440-461-2550
Mailing Address - Fax:
Practice Address - Street 1:6770 MAYFIELD RD
Practice Address - Street 2:SUITE 415
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2299
Practice Address - Country:US
Practice Address - Phone:440-461-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP08359363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2618920Medicaid
Q48315Medicare UPIN
OH2618920Medicaid