Provider Demographics
NPI:1760063572
Name:WALSH, SARA (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16765 S. LEROY LANE
Mailing Address - Street 2:
Mailing Address - City:OREGONCITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16765 S. LEROY LANE
Practice Address - Street 2:
Practice Address - City:OREGONCITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:971-241-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201140524RN163WL0100X
ID67356163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant