Provider Demographics
NPI:1871219220
Name:SCULLY, SARA RENEE (RN)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:RENEE
Last Name:SCULLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DENKERS DR
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-2228
Mailing Address - Country:US
Mailing Address - Phone:151-825-8874
Mailing Address - Fax:
Practice Address - Street 1:11 DENKERS DR
Practice Address - Street 2:
Practice Address - City:BALLSTON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12019-2228
Practice Address - Country:US
Practice Address - Phone:151-825-8874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY724776163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY724776OtherNURSING LICENSE, RN