Healthcare Provider Details

I. General information

NPI: 1053326934
Provider Name (Legal Business Name): SARA DERENGE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

IV. Provider business mailing address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-3892
  • Fax: 360-414-1114
Mailing address:
  • Phone: 360-636-3892
  • Fax: 360-414-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN00142323
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP30005950
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: