Healthcare Provider Details

I. General information

NPI: 1427865492
Provider Name (Legal Business Name): SARA PERISIN AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13011 S 104TH AVE STE 100
PALOS PARK IL
60464-1508
US

IV. Provider business mailing address

24428 S VALLEY DR
CHANNAHON IL
60410-5226
US

V. Phone/Fax

Practice location:
  • Phone: 708-274-3278
  • Fax: 708-274-3299
Mailing address:
  • Phone: 708-913-3375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209031235
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: