Provider Demographics
NPI:1083077796
Name:PHELAN, SARAH
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:
Last Name:PHELAN
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 1:28 S KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5608
Mailing Address - Country:US
Mailing Address - Phone:516-652-4663
Mailing Address - Fax:
Practice Address - Street 1:28 S KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5608
Practice Address - Country:US
Practice Address - Phone:516-652-4663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY656061174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY890337425OtherEMPIRE GOVERNMENT