Provider Demographics
NPI:1679857502
Name:NEVIL, SARA J (NP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:J
Last Name:NEVIL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:J
Other - Last Name:BENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8857
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-8857
Mailing Address - Country:US
Mailing Address - Phone:260-969-6200
Mailing Address - Fax:260-969-6201
Practice Address - Street 1:7900 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-969-6200
Practice Address - Fax:260-969-6201
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003707A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201057050Medicaid
INM400059750Medicare PIN