Healthcare Provider Details

I. General information

NPI: 1114240140
Provider Name (Legal Business Name): SARAH NISLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N SENATE AVE AG 401
INDIANAPOLIS IN
46202-5306
US

IV. Provider business mailing address

1701 N SENATE AVE AG 401
INDIANAPOLIS IN
46202-5306
US

V. Phone/Fax

Practice location:
  • Phone: 317-295-1805
  • Fax:
Mailing address:
  • Phone: 317-295-1805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26022611A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: