Provider Demographics
NPI:1710216676
Name:SANDOVAL, DEBRA LYNN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 LAKE HAVASU AVE S
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-0842
Mailing Address - Country:US
Mailing Address - Phone:928-846-4466
Mailing Address - Fax:928-846-4465
Practice Address - Street 1:116 LAKE HAVASU AVE S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-0842
Practice Address - Country:US
Practice Address - Phone:928-846-4466
Practice Address - Fax:928-846-4465
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory