Provider Demographics
NPI:1659042844
Name:SANDA, AYISHA (PMHNP-BC, APRN-CNP)
Entity type:Individual
Prefix:
First Name:AYISHA
Middle Name:
Last Name:SANDA
Suffix:
Gender:F
Credentials:PMHNP-BC, APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 BRETON DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2525
Mailing Address - Country:US
Mailing Address - Phone:503-662-9385
Mailing Address - Fax:503-782-8301
Practice Address - Street 1:3330 MATLOCK RD STE 202B
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2921
Practice Address - Country:US
Practice Address - Phone:503-662-9385
Practice Address - Fax:503-782-8301
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX897183163W00000X
OR202114666RN163WP0808X
OR202114948363LP0808X
TX1057466363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
15458727OtherCAQH ID
OR500802692Medicaid