Provider Demographics
NPI:1801244199
Name:DEZELL, SARA (RN)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:DEZELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1900
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-656-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 213472-5163WM0705X
MNCNS 0507364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical