Provider Demographics
NPI:1033688866
Name:ERNST, SARA JEANETTE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JEANETTE
Last Name:ERNST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 85TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-6498
Mailing Address - Country:US
Mailing Address - Phone:206-696-0590
Mailing Address - Fax:
Practice Address - Street 1:25 95TH DR NE STE 105
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-7976
Practice Address - Country:US
Practice Address - Phone:425-334-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-22
Last Update Date:2018-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60242495225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty