Provider Demographics
NPI:1144856063
Name:LUNDBERG, SARA CORNWELL (FNP-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:CORNWELL
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02841-1006
Mailing Address - Country:US
Mailing Address - Phone:401-841-3946
Mailing Address - Fax:
Practice Address - Street 1:1800 MAIN RD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-4625
Practice Address - Country:US
Practice Address - Phone:401-625-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN02422363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner