Provider Demographics
NPI:1063794659
Name:WALLIS, SARAH (MSN CNM WHNP-BC)
Entity type:Individual
Prefix:MS
First Name:SARAH
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MSN CNM WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7990 N BECK RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1204
Mailing Address - Country:US
Mailing Address - Phone:732-456-6262
Mailing Address - Fax:732-626-6579
Practice Address - Street 1:14355 MIRANDA WAY
Practice Address - Street 2:
Practice Address - City:LOS ALTOS HILLS
Practice Address - State:CA
Practice Address - Zip Code:94022-2032
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:833-775-1861
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA707787363LW0102X
MI4704362422363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health