Provider Demographics
NPI:1124691928
Name:SACKETT, SARA CHRISTINE (RDN)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:CHRISTINE
Last Name:SACKETT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:CHRISTINE
Other - Last Name:SHIRVANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4163 SUNRAY AVE S.
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:619-372-9799
Mailing Address - Fax:
Practice Address - Street 1:4163 SUNRAY AVE S.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:619-372-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR133V00000X
133VN1005X, 133VN1101X, 133VN1201X, 133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1101XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Gerontological
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics