Provider Demographics
NPI:1861909012
Name:TAGUE, SARAH (CNP)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:TAGUE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5212 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1718
Mailing Address - Country:US
Mailing Address - Phone:563-379-2103
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD STE 205N
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1586
Practice Address - Country:US
Practice Address - Phone:952-903-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5659363LP0808X
MN2200840163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health