Provider Demographics
NPI:1821773565
Name:MELLBERG, SARAH (RD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:MELLBERG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3134 SUMMER DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6726
Mailing Address - Country:US
Mailing Address - Phone:719-660-5096
Mailing Address - Fax:
Practice Address - Street 1:200 W HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86148367133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered