Provider Demographics
NPI:1760829543
Name:SANDOVAL, MARY MADRIGAL (RN, PHN, FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MADRIGAL
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:RN, PHN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5172
Mailing Address - Country:US
Mailing Address - Phone:909-864-1097
Mailing Address - Fax:
Practice Address - Street 1:607 DONNA WAY
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5517
Practice Address - Country:US
Practice Address - Phone:951-654-0803
Practice Address - Fax:951-654-3917
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA531242163WC1500X
CA95013490363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95013490OtherBOARD OF REGISTERED NURSING
CA59378OtherBOARD OF REGISTERED NURSING
CA531242OtherBOARD OF REGISTERED NURSING