Provider Demographics
NPI:1215297916
Name:SANDICO, CARRIE MICHELLE FAMATID (LVN)
Entity type:Individual
Prefix:
First Name:CARRIE MICHELLE
Middle Name:FAMATID
Last Name:SANDICO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 ALYSSA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-1309
Mailing Address - Country:US
Mailing Address - Phone:408-904-8288
Mailing Address - Fax:
Practice Address - Street 1:6551 ALYSSA DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138-1309
Practice Address - Country:US
Practice Address - Phone:408-904-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 248115164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSANDICO13Medicaid