Provider Demographics
NPI:1659042844
Name:SANDA, AYISHA (PMHNP-BC, APRN-CNP)
Entity Type:Individual
Prefix:
First Name:AYISHA
Middle Name:
Last Name:SANDA
Suffix:
Gender:F
Credentials:PMHNP-BC, APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5331 S MACADAM AVE STE 258
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3871
Mailing Address - Country:US
Mailing Address - Phone:469-999-0416
Mailing Address - Fax:469-999-0416
Practice Address - Street 1:547 BRETON DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2525
Practice Address - Country:US
Practice Address - Phone:316-304-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202114666RN163WP0808X
OR202114948363LP0808X
TX1057466363LP0808X
TX897183163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500802692Medicaid
15458727OtherCAQH ID