Provider Demographics
NPI:1285183582
Name:O'DONNELL, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:LOUISE
Other - Last Name:LAVERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSFA
Mailing Address - Street 1:1604 SANBORN ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1908
Mailing Address - Country:US
Mailing Address - Phone:810-434-3957
Mailing Address - Fax:
Practice Address - Street 1:1604 SANBORN ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-1908
Practice Address - Country:US
Practice Address - Phone:810-434-3957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI125347OtherNATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING