Healthcare Provider Details

I. General information

NPI: 1821317405
Provider Name (Legal Business Name): SARA ELLEN HASSELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 03/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13321 VENDETTA WAY UNIT 101
LOUISVILLE KY
40245-7631
US

IV. Provider business mailing address

13321 VENDETTA WAY UNIT 101
LOUISVILLE KY
40245-7631
US

V. Phone/Fax

Practice location:
  • Phone: 985-772-1551
  • Fax: 502-241-2602
Mailing address:
  • Phone: 985-772-1551
  • Fax: 502-241-2602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number169345
License Number StateKY

VIII. Authorized Official

Name: SARA ELLEN HASSELL
Title or Position: REGISTERED DIETITIAN
Credential: RD, CN, LD
Phone: 985-772-1551