Provider Demographics
NPI:1497284608
Name:KLAVERWEIDEN, SARAH BRICE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:BRICE
Last Name:KLAVERWEIDEN
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 1:301 BROOKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-3907
Mailing Address - Country:US
Mailing Address - Phone:443-557-8411
Mailing Address - Fax:
Practice Address - Street 1:301 BROOKVIEW DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-3907
Practice Address - Country:US
Practice Address - Phone:410-973-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2023-11-27
Deactivation Date:2021-08-24
Deactivation Code:
Reactivation Date:2023-08-21
Provider Licenses
StateLicense IDTaxonomies
MDDX4436133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483106300Medicaid