Provider Demographics
NPI:1295000651
Name:SANDANA, GLADYS (LE, CME, COE, CPCP)
Entity Type:Individual
Prefix:MS
First Name:GLADYS
Middle Name:
Last Name:SANDANA
Suffix:
Gender:F
Credentials:LE, CME, COE, CPCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 VALLEY AVE NE
Mailing Address - Street 2:#16
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-6965
Mailing Address - Country:US
Mailing Address - Phone:253-948-7127
Mailing Address - Fax:
Practice Address - Street 1:1424 49TH ST NE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98422-1818
Practice Address - Country:US
Practice Address - Phone:253-948-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602869350174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602869350Medicaid