Provider Demographics
NPI:1558878439
Name:WALL, SARA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 E FRANKLIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2816
Mailing Address - Country:US
Mailing Address - Phone:199-240-7269
Mailing Address - Fax:
Practice Address - Street 1:1512 E FRANKLIN ST STE 100
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2816
Practice Address - Country:US
Practice Address - Phone:919-240-7269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016835363LF0000X
NC5017328363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid