Provider Demographics
NPI:1184682775
Name:NICHOLSON, SARA KRISTEN (OD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:KRISTEN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SARA
Other - Middle Name:KRISTEN
Other - Last Name:LEGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1534 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1949
Mailing Address - Country:US
Mailing Address - Phone:262-989-9629
Mailing Address - Fax:
Practice Address - Street 1:4060 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3121
Practice Address - Country:US
Practice Address - Phone:262-752-2020
Practice Address - Fax:262-292-5019
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2990-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V02337Medicare UPIN