Provider Demographics
NPI:1902816143
Name:SARE, SALLY (NP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:SARE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 S. MAXWELL ST.
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N JORDAN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3190
Practice Address - Country:US
Practice Address - Phone:812-855-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001843363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health