Basic Information
Provider Information | |||||||||
NPI: | 1598045361 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAES | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | RHIANNON | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17800 US HIGHWAY 18 | ||||||||
Address2: |   | ||||||||
City: | APPLE VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 923071221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7605526700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17800 US HIGHWAY 18 | ||||||||
Address2: |   | ||||||||
City: | APPLE VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 923071221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7605526700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2011 | ||||||||
LastUpdateDate: | 08/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X |   |   | Y |   | Other Service Providers | Community Health Worker |   |
No ID Information.