Healthcare Provider Details

I. General information

NPI: 1144661380
Provider Name (Legal Business Name): SOTHIDA BERRY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SOTHIDA SURACHAICHARN RN

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

IV. Provider business mailing address

1135 S DELANO CT E APT 427
CHICAGO IL
60605-3457
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-4029
  • Fax: 815-936-4032
Mailing address:
  • Phone: 219-669-9505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number93131
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: