=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295612992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN PEDLEY DNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2025
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 SILVER CROSS BLVD
-----------------------------------------------------
City | NEW LENOX
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60451-9509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-300-7910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 SILVER CROSS BLVD
-----------------------------------------------------
City | NEW LENOX
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60451-9509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-300-7910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 041589145
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 209.033187
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------