Provider Demographics
NPI:1952495277
Name:CAROLLO, SANDRA (ARNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:CAROLLO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-0959
Mailing Address - Country:US
Mailing Address - Phone:509-575-4084
Mailing Address - Fax:
Practice Address - Street 1:402 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3546
Practice Address - Country:US
Practice Address - Phone:509-575-4084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
18214OtherGROUP HEALTH
WA123346OtherL & I
WA9392CAOtherREGENCE
911019392OtherCOMMERCIAL
WA9622333Medicaid
WA9622333OtherCHPW
GAB16270Medicare ID - Type Unspecified
911019392OtherCOMMERCIAL
WA9392CAOtherREGENCE