Healthcare Provider Details

I. General information

NPI: 1003419797
Provider Name (Legal Business Name): SARA PEDERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 09/11/2025
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 PENNSYLVANIA AVE
DELAWARE OH
43015-1519
US

IV. Provider business mailing address

379 PENNSYLVANIA AVE
DELAWARE OH
43015-1519
US

V. Phone/Fax

Practice location:
  • Phone: 740-816-3669
  • Fax:
Mailing address:
  • Phone: 740-816-3669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberSV099550
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: