Provider Demographics
NPI:1871861351
Name:PORTILLO, SANDRA FAYE
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:FAYE
Last Name:PORTILLO
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 1:313 RUTGER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-3063
Mailing Address - Country:US
Mailing Address - Phone:315-731-0147
Mailing Address - Fax:
Practice Address - Street 1:313 RUTGER ST APT 3
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-3063
Practice Address - Country:US
Practice Address - Phone:315-731-0147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160467-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse