Provider Demographics
NPI:1053815753
Name:SWANSON, SARAH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 OXFORD RD APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2635
Mailing Address - Country:US
Mailing Address - Phone:815-354-4603
Mailing Address - Fax:
Practice Address - Street 1:16 OXFORD RD APT 3
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2635
Practice Address - Country:US
Practice Address - Phone:815-354-4603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86010749133V00000X
NY008318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered