Provider Demographics
NPI:1306317250
Name:WILLARD, SARAH (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 VIEUX MARCHE MALL
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530-3822
Mailing Address - Country:US
Mailing Address - Phone:228-436-9204
Mailing Address - Fax:
Practice Address - Street 1:784 VIEUX MARCHE MALL
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-3822
Practice Address - Country:US
Practice Address - Phone:228-436-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86070480133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86070480OtherCOMMISSION ON DIETETIC REGISTRATION
MSD1952OtherMISSISSIPPI STATE DEPARTMENT OF HEALTH