Provider Demographics
NPI:1568659845
Name:CRUSSANA, SARA NICHOL (OD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:NICHOL
Last Name:CRUSSANA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-5928
Mailing Address - Country:US
Mailing Address - Phone:401-255-9503
Mailing Address - Fax:
Practice Address - Street 1:17 WELLS ST STE 101
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2923
Practice Address - Country:US
Practice Address - Phone:401-348-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3049152W00000X
VA0618002621152W00000X
PAOEG002217152W00000X
WAOD 60284399152W00000X
RIODTG00708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA46-3620513OtherEIN