Basic Information
| Provider Information | |||||||||
| NPI: | 1013996180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDALL | ||||||||
| FirstName: | CORIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9230 SKY ISLAND DR E | ||||||||
| Address2: | |||||||||
| City: | BONNEY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983917385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537506000 | ||||||||
| FaxNumber: | 2537506100 | ||||||||
| Practice Location | |||||||||
| Address1: | 9230 SKY ISLAND DR E | ||||||||
| Address2: | |||||||||
| City: | BONNEY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983917385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537506000 | ||||||||
| FaxNumber: | 2537506100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00045674 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0210070 | 01 | WA | STATE L&I | OTHER |