Provider Demographics
NPI:1376765685
Name:SANDOVAL, MARICELA (APRN, BC)
Entity Type:Individual
Prefix:MRS
First Name:MARICELA
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6137 S MAYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-4405
Mailing Address - Country:US
Mailing Address - Phone:773-702-1000
Mailing Address - Fax:773-834-7068
Practice Address - Street 1:5758 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1426
Practice Address - Country:US
Practice Address - Phone:773-702-1000
Practice Address - Fax:773-834-7068
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily