Provider Demographics
NPI:1861379703
Name:SANDOVAL, MARISOL
Entity type:Individual
Prefix:
First Name:MARISOL
Middle Name:
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 1:1608 S ELDER AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-6305
Mailing Address - Country:US
Mailing Address - Phone:918-565-9930
Mailing Address - Fax:
Practice Address - Street 1:1608 S ELDER AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6305
Practice Address - Country:US
Practice Address - Phone:918-565-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator