Provider Demographics
NPI:1053705392
Name:SANDOVAL, SHEARITA (ANP- BC)
Entity type:Individual
Prefix:
First Name:SHEARITA
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:ANP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5471 DR. MARTIN LUTHER KING DR.
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-6326
Practice Address - Street 1:3113 MAGNOLIA AVE
Practice Address - Street 2:APT 2E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-1271
Practice Address - Country:US
Practice Address - Phone:314-749-6708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014043293363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health