Provider Demographics
NPI:1609419282
Name:LETELLIER, SARA (CG 60819011)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:LETELLIER
Suffix:
Gender:F
Credentials:CG 60819011
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4627
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-0627
Mailing Address - Country:US
Mailing Address - Phone:509-624-1244
Mailing Address - Fax:
Practice Address - Street 1:2308 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-5810
Practice Address - Country:US
Practice Address - Phone:206-931-8825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60819011175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist