Basic Information
| Provider Information | |||||||||
| NPI: | 1366946956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ITTEILAG | ||||||||
| FirstName: | SARAH ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | AGACNP BC MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 SHORE RD | ||||||||
| Address2: | |||||||||
| City: | WESTERLY | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028914206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012753608 | ||||||||
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| Practice Location | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602714364 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2018 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 7503 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.