Provider Demographics
NPI:1063280188
Name:SUAZO, SANDRA MICHELLE (CHW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MICHELLE
Last Name:SUAZO
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2245
Mailing Address - Country:US
Mailing Address - Phone:505-287-6506
Mailing Address - Fax:505-287-5393
Practice Address - Street 1:1423 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2245
Practice Address - Country:US
Practice Address - Phone:505-287-6506
Practice Address - Fax:505-287-5393
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMS1-1471172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker