MEDICARE: SOPHIE ANN TOOTELIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide

General Provider Information

NPI Number	:	1093328031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIE ANN TOOTELIAN

Provider Business Mailing Address
First Line	:	8334 N WADDAMS GROVE RD
Second Line	:
City	:	LENA
State	:	IL
Zip	:	61048-9750
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8334 N WADDAMS GROVE RD
Second Line	:
City	:	LENA
State	:	IL
Zip	:	61048-9750
Country	:	US
Telephone Number	:	815-908-3444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2020
Last Update Date	:	08/28/2020

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Directions to “ SOPHIE ANN TOOTELIAN ” Practice Location

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