Basic Information
Provider Information | |||||||||
NPI: | 1831548478 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ACOSTA | ||||||||
FirstName: | SARA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCHLICHTING | ||||||||
OtherFirstName: | SARA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3880 SALEM LAKE DR STE F | ||||||||
Address2: |   | ||||||||
City: | LONG GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 600475292 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8477192220 | ||||||||
FaxNumber: | 8477192265 | ||||||||
Practice Location | |||||||||
Address1: | 3880 SALEM LAKE DR STE F | ||||||||
Address2: |   | ||||||||
City: | LONG GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 600475292 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8477192220 | ||||||||
FaxNumber: | 8477192265 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2016 | ||||||||
LastUpdateDate: | 03/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 209014208 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 209014208 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 209014208 | 05 | IL |   | MEDICAID | MS4323200 | 01 | IL | DEA | OTHER |