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General NPI Number Information
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NPI Number | 1184853269
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Entity Type | Individual
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Provider Name | SARA LAUREN FETTY AUD
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Gender | Female
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Dates
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Enumeration Date | 07/09/2009
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Last Update Date | 10/22/2019
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Provider Practice Location Address
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Address Line | 620 JOHN PAUL JONES CIR
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City | PORTSMOUTH
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State | VA
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Zip | 23708-2111
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Country | US
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Telephone | 757-953-2828
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Fax | 757-953-0848
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Provider Business Mailing Address
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Address Line | CENTRALIZED CREDENTIALS & PRIVILEGING DIRECTORATE 554 KEILY STREET
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City | JACKSONVILLE
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State | FL
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Zip | 32212-3049
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Country | US
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Telephone | 757-953-7550
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Fax | 757-953-0090
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 2201001400
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License Number State | VA
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