Provider Demographics
NPI:1013444892
Name:NIETO, SANDRA (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:NIETO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-2233
Mailing Address - Country:US
Mailing Address - Phone:432-582-2882
Mailing Address - Fax:432-582-2884
Practice Address - Street 1:4060 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-2233
Practice Address - Country:US
Practice Address - Phone:432-582-2882
Practice Address - Fax:432-582-2884
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133121363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX372353802Medicaid