Healthcare Provider Details

I. General information

NPI: 1942872957
Provider Name (Legal Business Name): SARA CUPP CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2021
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 MCAULEY DR
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

1860 KORTE ST
HARTLAND MI
48353-3310
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-4090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704308030
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704308030
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: