Provider Demographics
NPI:1295385235
Name:SANDOVAL, ANGELA MARIE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
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 1:857 S IRONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-1219
Mailing Address - Country:US
Mailing Address - Phone:909-213-4852
Mailing Address - Fax:
Practice Address - Street 1:857 S IRONWOOD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-1219
Practice Address - Country:US
Practice Address - Phone:909-213-4852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider