Provider Demographics
NPI:1174592240
Name:RUPP, SARA ELIZABETH (ATC, RN)
Entity type:Individual
Prefix:MISS
First Name:SARA
Middle Name:ELIZABETH
Last Name:RUPP
Suffix:
Gender:F
Credentials:ATC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5728 THORNBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3875
Mailing Address - Country:US
Mailing Address - Phone:260-485-2418
Mailing Address - Fax:
Practice Address - Street 1:5050 NORTH CLINTON
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28151799A163W00000X
IN36000457A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer