Provider Demographics
NPI:1568762011
Name:SANDOVAL, LORETTA (RN, CNM)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:RN, CNM
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:
Other - Last Name:GOREVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3617 S PACIFIC HWY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-8957
Mailing Address - Country:US
Mailing Address - Phone:541-535-6239
Mailing Address - Fax:541-512-1026
Practice Address - Street 1:3617 S PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-8957
Practice Address - Country:US
Practice Address - Phone:541-535-6239
Practice Address - Fax:541-512-1026
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201042847RN163W00000X
OR201250116NP363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse