Healthcare Provider Details

I. General information

NPI: 1578041828
Provider Name (Legal Business Name): SARAH NICHOLE NORTHCUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12517 NICHOLAS PL
RHOME TX
76078-6064
US

IV. Provider business mailing address

12517 NICHOLAS PL
RHOME TX
76078-6064
US

V. Phone/Fax

Practice location:
  • Phone: 817-602-8918
  • Fax:
Mailing address:
  • Phone: 817-602-8918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number172339
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number376962
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: