Basic Information
| Provider Information | |||||||||
| NPI: | 1952495277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAROLLO | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 959 | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989070959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095754084 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 402 S 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989023546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095754084 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP30004738 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 18214 | 01 | GROUP HEALTH | OTHER | 123346 | 01 | WA | L & I | OTHER | 9392CA | 01 | WA | REGENCE | OTHER | 911019392 | 01 | COMMERCIAL | OTHER | 9622333 | 05 | WA | MEDICAID | 9622333 | 01 | WA | CHPW | OTHER |