Provider Demographics
NPI:1063680726
Name:SOLLY, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SOLLY
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 1:2002 LIFE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75212-2448
Mailing Address - Country:US
Mailing Address - Phone:409-423-0694
Mailing Address - Fax:
Practice Address - Street 1:2002 LIFE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-2448
Practice Address - Country:US
Practice Address - Phone:409-423-0694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00002049133V00000X
TXDT81099133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7401961Medicaid