Provider Demographics
NPI:1093597031
Name:NYBRO, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:NYBRO
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 1:15 RESERVOIR DR
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-6808
Mailing Address - Country:US
Mailing Address - Phone:917-675-2376
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:516-806-5719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY666163961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist