Provider Demographics
NPI:1073167250
Name:CUPP, SARAH (FNP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:CUPP
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 1:19621 S LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9360
Mailing Address - Country:US
Mailing Address - Phone:708-478-3603
Mailing Address - Fax:708-478-3036
Practice Address - Street 1:19621 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9360
Practice Address - Country:US
Practice Address - Phone:708-478-8380
Practice Address - Fax:708-478-3036
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily