Provider Demographics
NPI:1770093171
Name:CRAIN, SANDRE LEONA (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SANDRE
Middle Name:LEONA
Last Name:CRAIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9718 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1007
Mailing Address - Country:US
Mailing Address - Phone:773-233-4100
Mailing Address - Fax:
Practice Address - Street 1:17066 S PARK AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-3369
Practice Address - Country:US
Practice Address - Phone:708-882-0532
Practice Address - Fax:647-799-2792
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016571363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty