Provider Demographics
NPI:1912232521
Name:SANDOVAL, SHANNON ELIZABETH (LPN)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 GUARA LANE
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:575-758-2494
Mailing Address - Fax:
Practice Address - Street 1:413 SIPAPU ROAD
Practice Address - Street 2:# 6952
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-5857
Practice Address - Fax:575-758-5857
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML20200164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse