Provider Demographics
NPI:1255760336
Name:FETYKO, SARA ANN (LAC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ANN
Last Name:FETYKO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1707
Mailing Address - Country:US
Mailing Address - Phone:612-207-3660
Mailing Address - Fax:
Practice Address - Street 1:136 N 1ST AVE E
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1203
Practice Address - Country:US
Practice Address - Phone:612-207-3660
Practice Address - Fax:218-242-8409
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1694171100000X
MN1490171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty