Provider Demographics
NPI:1346821311
Name:FAZEL, SARAH SHANTI
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:SHANTI
Last Name:FAZEL
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 1:219 S DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5315
Mailing Address - Country:US
Mailing Address - Phone:208-965-1955
Mailing Address - Fax:
Practice Address - Street 1:IDAHO DEPARTMENT OF HEALTH AND WELFARE
Practice Address - Street 2:1720 WESTGATE DR. SUITE D
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-334-0921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist