Healthcare Provider Details

I. General information

NPI: 1649461583
Provider Name (Legal Business Name): SALLY L SPROWL EAGAR RN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SALLY L FULLER

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 STONE ST
AUGUSTA ME
04330-5227
US

IV. Provider business mailing address

66 STONE ST
AUGUSTA ME
04330-5227
US

V. Phone/Fax

Practice location:
  • Phone: 207-626-3455
  • Fax: 207-626-3612
Mailing address:
  • Phone: 207-626-3455
  • Fax: 207-626-3612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR036740
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: