Provider Demographics
NPI:1033866199
Name:PETTRY-SOTO, SARAH (FNP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:PETTRY-SOTO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:27240 W SAXONY DR STE 201
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-1417
Practice Address - Country:US
Practice Address - Phone:815-467-1518
Practice Address - Fax:815-467-7419
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041439278163W00000X
IL209023108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.023108OtherIL LICENSE