Provider Demographics
NPI:1811996515
Name:STOVALL-WILSON, SANDRA DENNIESE (LVN)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:DENNIESE
Last Name:STOVALL-WILSON
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 1:190 SIERRA CT
Mailing Address - Street 2:SUITE B217
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-7607
Mailing Address - Country:US
Mailing Address - Phone:661-273-3755
Mailing Address - Fax:661-273-3755
Practice Address - Street 1:190 SIERRA CT
Practice Address - Street 2:SUITE B217
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7607
Practice Address - Country:US
Practice Address - Phone:661-273-3755
Practice Address - Fax:661-273-3755
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152808164X00000X
3747P1801X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered164X00000XNursing Service ProvidersLicensed Vocational Nurse
Not Answered3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Not Answered374U00000XNursing Service Related ProvidersHome Health Aide