Provider Demographics
NPI:1316102643
Name:BETTERLY WALLEN, SARA RAE
Entity type:Individual
Prefix:DR
First Name:SARA
Middle Name:RAE
Last Name:BETTERLY WALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SARA
Other - Middle Name:RAE
Other - Last Name:BETTERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:712 HAGUE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6951
Mailing Address - Country:US
Mailing Address - Phone:651-210-6202
Mailing Address - Fax:
Practice Address - Street 1:2330 SIOUX TRL NW
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-9077
Practice Address - Country:US
Practice Address - Phone:952-233-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3116152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist