Basic Information
| Provider Information | |||||||||
| NPI: | 1760975767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICOL | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 47 NEW SCOTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182625226 | ||||||||
| FaxNumber: | 5182626261 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 NEW SCOTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182625226 | ||||||||
| FaxNumber: | 5182626261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2018 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 745357 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 343368 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 05323602 | 05 | NY | MEDICAID | 343368 | 01 | NY | NEW YORK STATE OFFICE OF THE PROFESSIONS | OTHER |