Healthcare Provider Details

I. General information

NPI: 1720713233
Provider Name (Legal Business Name): SARAH LYNN OLMEDO-JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 SAINT ANN AVE
BILOXI MS
39531-3416
US

IV. Provider business mailing address

1612 SAINT ANN AVE
BILOXI MS
39531-3416
US

V. Phone/Fax

Practice location:
  • Phone: 228-261-3645
  • Fax:
Mailing address:
  • Phone: 228-261-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4945G
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM8998
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number116727
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: