Provider Demographics
NPI:1376188110
Name:SANDOVAL, DIANA IRAIS (APRN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:IRAIS
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W TAYLOR ST STE C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4795
Mailing Address - Country:US
Mailing Address - Phone:312-413-3631
Mailing Address - Fax:312-355-3133
Practice Address - Street 1:1801 W TAYLOR ST STE C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-413-3631
Practice Address - Fax:312-355-3133
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041422080163W00000X
IL2020089466363LF0000X
IL209022504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse