MEDICARE: SARAH MONROE PETTRY REGISTERED DIETITIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT84692	TX

General Provider Information

NPI Number	:	1720778400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH MONROE PETTRY REGISTERED DIETITIAN

Provider Business Mailing Address
First Line	:	7405 TRAVERTINE SPRING DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78744-4571
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7405 TRAVERTINE SPRING DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78744-4571
Country	:	US
Telephone Number	:	256-591-2122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	05/10/2023

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