Provider Demographics
NPI:1033783782
Name:MIRRA, SARA (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:MIRRA
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 SHARON DR
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-2298
Mailing Address - Country:US
Mailing Address - Phone:570-675-0692
Mailing Address - Fax:
Practice Address - Street 1:2872 TURNPIKE ST
Practice Address - Street 2:
Practice Address - City:SUSQUEHANNA
Practice Address - State:PA
Practice Address - Zip Code:18847-2771
Practice Address - Country:US
Practice Address - Phone:800-323-2051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN007366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA31087390Medicaid