Provider Demographics
NPI:1952573289
Name:THELEN, SARAH MOON (MD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:MOON
Last Name:THELEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:MARIE
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-0038
Mailing Address - Country:US
Mailing Address - Phone:931-227-4984
Mailing Address - Fax:931-227-4985
Practice Address - Street 1:305 COLLEGE ST W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2911
Practice Address - Country:US
Practice Address - Phone:931-227-4984
Practice Address - Fax:931-227-4985
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD46417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4293092OtherBLUE CROSS BLUE SHIELD TENNESSEE
TN1522807Medicaid
TN103G700423OtherMEDICARE GROUP
TN103G700423OtherMEDICARE GROUP