Provider Demographics
NPI:1053326934
Name:DERENGE, SARA (ARNP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:DERENGE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-636-3892
Mailing Address - Fax:360-414-1114
Practice Address - Street 1:1057 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2509
Practice Address - Country:US
Practice Address - Phone:360-636-3892
Practice Address - Fax:360-414-1114
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00142323163WG0000X
WAAP30005950363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9632449Medicaid
WAAB25807Medicare ID - Type Unspecified
WA9632449Medicaid