Healthcare Provider Details

I. General information

NPI: 1861320723
Provider Name (Legal Business Name): SAMIRATOU SOUDRE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20201 CRAWFORD AVE
OLYMPIA FIELDS IL
60461-1010
US

IV. Provider business mailing address

2337 BILSTONE DR
LYNWOOD IL
60411-1577
US

V. Phone/Fax

Practice location:
  • Phone: 708-855-7100
  • Fax: 708-503-3296
Mailing address:
  • Phone: 773-807-2092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.035147
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: