Basic Information
| Provider Information | |||||||||
| NPI: | 1467099069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMPAGNE | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERTEL | ||||||||
| OtherFirstName: | SARA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 175 CONNORS ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | GARDNER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014402637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788446 | ||||||||
| FaxNumber: | 9784106102 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 CONNORS ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | GARDNER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014402637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788446 | ||||||||
| FaxNumber: | 9784106102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2019 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN2270444 | MA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.