Healthcare Provider Details

I. General information

NPI: 1912475344
Provider Name (Legal Business Name): SARA VIVIAN TELLO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2018
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4407 6TH ST
LUBBOCK TX
79416-4733
US

IV. Provider business mailing address

4512 93RD DR
LUBBOCK TX
79424-5114
US

V. Phone/Fax

Practice location:
  • Phone: 806-771-5864
  • Fax: 806-771-9009
Mailing address:
  • Phone: 806-928-1144
  • Fax: 806-771-9009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAP139612
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP139612
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: