Provider Demographics
NPI:1851820260
Name:MANDUJANO, SARAH ANN (LAT, ATC)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:ANN
Last Name:MANDUJANO
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:MRS
Other - First Name:SARAH
Other - Middle Name:ANN
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:3623 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4985
Mailing Address - Country:US
Mailing Address - Phone:909-549-0801
Mailing Address - Fax:
Practice Address - Street 1:3623 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4985
Practice Address - Country:US
Practice Address - Phone:909-549-0801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
AZ0095242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer