Healthcare Provider Details

I. General information

NPI: 1073167250
Provider Name (Legal Business Name): SARAH CUPP FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 05/02/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11243 W LAPORTE RD
MOKENA IL
60448
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 708-479-4681
  • Fax: 708-479-8516
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019637
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: