Provider Demographics
NPI:1568288405
Name:WALSH, SARA JEAN (CDN)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JEAN
Last Name:WALSH
Suffix:
Gender:F
Credentials:CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WILLIAMS ST W
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2214
Mailing Address - Country:US
Mailing Address - Phone:860-281-6741
Mailing Address - Fax:
Practice Address - Street 1:121 WILLIAMS ST W
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2214
Practice Address - Country:US
Practice Address - Phone:860-281-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03-157787133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist