Provider Demographics
NPI:1578041828
Name:NORTHCUTT, SARAH NICHOLE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:NICHOLE
Last Name:NORTHCUTT
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 1:12517 NICHOLAS PL
Mailing Address - Street 2:
Mailing Address - City:RHOME
Mailing Address - State:TX
Mailing Address - Zip Code:76078-6064
Mailing Address - Country:US
Mailing Address - Phone:817-602-8918
Mailing Address - Fax:
Practice Address - Street 1:12517 NICHOLAS PL
Practice Address - Street 2:
Practice Address - City:RHOME
Practice Address - State:TX
Practice Address - Zip Code:76078-6064
Practice Address - Country:US
Practice Address - Phone:817-602-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172339246ZS0410X
ID376962247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172339OtherNBSTSA
ID376962OtherARRT