Provider Demographics
NPI:1548133515
Name:FAVA, SARA ASHLEY
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ASHLEY
Last Name:FAVA
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 1:841 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3848
Mailing Address - Country:US
Mailing Address - Phone:760-985-4467
Mailing Address - Fax:
Practice Address - Street 1:222 E MAIN ST STE 117
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2365
Practice Address - Country:US
Practice Address - Phone:760-255-1496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist