Provider Demographics
NPI:1922136555
Name:SANDOVAL, MAGGIE R (NMW)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:R
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:NMW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W ELM AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-3318
Mailing Address - Country:US
Mailing Address - Phone:213-484-8987
Mailing Address - Fax:213-484-8605
Practice Address - Street 1:635 S WESTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3508
Practice Address - Country:US
Practice Address - Phone:213-484-8987
Practice Address - Fax:213-484-8605
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW01110367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW011100Medicaid