Provider Demographics
NPI:1225546856
Name:TETTELBACH, SARA K
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:K
Last Name:TETTELBACH
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 1:5777 LOST GROVE DR NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-6161
Mailing Address - Country:US
Mailing Address - Phone:770-905-9822
Mailing Address - Fax:
Practice Address - Street 1:5777 LOST GROVE DR NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-6161
Practice Address - Country:US
Practice Address - Phone:770-905-9822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula