Healthcare Provider Details

I. General information

NPI: 1497397392
Provider Name (Legal Business Name): SARAH SHERMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10602 N PORT WASHINGTON RD STE 101
MEQUON WI
53092-5079
US

IV. Provider business mailing address

7027 N SENECA AVE
GLENDALE WI
53217-3869
US

V. Phone/Fax

Practice location:
  • Phone: 414-367-6376
  • Fax:
Mailing address:
  • Phone: 262-617-8966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86143536
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: