Provider Demographics
NPI:1184853269
Name:FETTY, SARA LAUREN (AUD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LAUREN
Last Name:FETTY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:LAUREN
Other - Last Name:BILLARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:CENTRALIZED CREDENTIALS & PRIVILEGING DIRECTORATE
Mailing Address - Street 2:554 KEILY STREET
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-3049
Mailing Address - Country:US
Mailing Address - Phone:757-953-7550
Mailing Address - Fax:757-953-0090
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-2828
Practice Address - Fax:757-953-0848
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001400231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1184853269Medicaid
VAP00736121Medicare PIN
VA020271R53Medicare PIN