Basic Information
| Provider Information | |||||||||
| NPI: | 1770093171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRAIN | ||||||||
| FirstName: | SANDRE | ||||||||
| MiddleName: | LEONA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9718 S HALSTED ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606281007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732334100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17066 S PARK AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HOLLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604733369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088820532 | ||||||||
| FaxNumber: | 6477992792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2017 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.016571 | IL | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 209.016571 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.