Healthcare Provider Details

I. General information

NPI: 1417929704
Provider Name (Legal Business Name): SARAH SOUTHARD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HIGHLAND AVE SE
ROANOKE VA
24013-2254
US

IV. Provider business mailing address

118 PAR DR
SALEM VA
24153-6811
US

V. Phone/Fax

Practice location:
  • Phone: 540-985-9835
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001-078793
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024078793
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: