Provider Demographics
NPI:1407092737
Name:ANDERSON, SARA ANN
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ANN
Last Name:ANDERSON
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 1:2691 SHADE TREE LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313
Mailing Address - Country:US
Mailing Address - Phone:920-737-9687
Mailing Address - Fax:
Practice Address - Street 1:2691 SHADE TREE LN
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313
Practice Address - Country:US
Practice Address - Phone:920-737-9687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI153503-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse