Provider Demographics
NPI:1427241504
Name:INTRAVAIA, SARAH ELIZABETH (MT)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:ELIZABETH
Last Name:INTRAVAIA
Suffix:
Gender:F
Credentials:MT
Other - Prefix:MISS
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MLT
Mailing Address - Street 1:1503 DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62951-2022
Mailing Address - Country:US
Mailing Address - Phone:618-983-5674
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225215246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist