Provider Demographics
NPI:1821399759
Name:SANDOVAL, SHARLENE NICOLE
Entity Type:Individual
Prefix:MRS
First Name:SHARLENE
Middle Name:NICOLE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHARLENE
Other - Middle Name:NICOLE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-0185
Mailing Address - Country:US
Mailing Address - Phone:575-756-8820
Mailing Address - Fax:
Practice Address - Street 1:ST RD 531 BLDG 1
Practice Address - Street 2:
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87575
Practice Address - Country:US
Practice Address - Phone:575-588-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist