Healthcare Provider Details

I. General information

NPI: 1417621541
Provider Name (Legal Business Name): SARAH TISSER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 LANDWEHR RD
NORTHBROOK IL
60062-2309
US

IV. Provider business mailing address

725 PINE ST
DEERFIELD IL
60015-4011
US

V. Phone/Fax

Practice location:
  • Phone: 224-306-9464
  • Fax: 224-306-9524
Mailing address:
  • Phone: 818-263-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number036083810
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277003835
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036083810
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: