Healthcare Provider Details

I. General information

NPI: 1982061768
Provider Name (Legal Business Name): SARA MEZZANO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 STEWART AVE
SAINT PAUL MN
55102-4117
US

IV. Provider business mailing address

680 STEWART AVE
SAINT PAUL MN
55102-4117
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-2477
  • Fax:
Mailing address:
  • Phone: 651-292-2477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberR2220370
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: