Provider Demographics
NPI:1740835669
Name:DOLEZAL, SARA THERESA (RN BSN IBCLC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:THERESA
Last Name:DOLEZAL
Suffix:
Gender:F
Credentials:RN BSN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18018 BURKE ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-4417
Mailing Address - Country:US
Mailing Address - Phone:402-573-7337
Mailing Address - Fax:
Practice Address - Street 1:18018 BURKE ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-4417
Practice Address - Country:US
Practice Address - Phone:402-573-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE87901163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE57901Medicaid
NE57901OtherPRIVATE