Provider Demographics
NPI:1144493404
Name:BAKKEN, SARA M (PT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:M
Last Name:BAKKEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 JUPITER DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-2950
Mailing Address - Country:US
Mailing Address - Phone:608-663-8706
Mailing Address - Fax:608-251-2868
Practice Address - Street 1:718 JUPITER DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2950
Practice Address - Country:US
Practice Address - Phone:608-663-8706
Practice Address - Fax:608-251-2868
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5541-024314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40281600Medicaid