Provider Demographics
NPI:1720692494
Name:SANDOVAL, MEMPHIS CHARDELL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MEMPHIS
Middle Name:CHARDELL
Last Name:SANDOVAL
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 523882
Mailing Address - Street 2:C/O THE MAILBOX #10649
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33152-3882
Mailing Address - Country:US
Mailing Address - Phone:317-498-1171
Mailing Address - Fax:317-219-0879
Practice Address - Street 1:3203 DOGWOOD LN
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-9629
Practice Address - Country:US
Practice Address - Phone:317-498-1171
Practice Address - Fax:317-219-0879
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704299093363L00000X, 363LP0808X
NV863235363LP0808X
IN71014109A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner