Provider Demographics
NPI:1316664956
Name:WATERBURY, SARA (DNP, PMHNP-BC, RN)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WATERBURY
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-1371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1680 SW BAYSHORE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-3518
Practice Address - Country:US
Practice Address - Phone:772-249-2597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9392585163W00000X
FLAPRN11022114363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse