Provider Demographics
NPI:1245748219
Name:ELLEFSON, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:ELLEFSON
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 1:1435 VILLAGE DR DEPT 2805
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84408-2805
Mailing Address - Country:US
Mailing Address - Phone:801-626-7656
Mailing Address - Fax:
Practice Address - Street 1:1435 VILLAGE DR DEPT 2805
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408-2805
Practice Address - Country:US
Practice Address - Phone:801-626-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS