Provider Demographics
NPI:1093328031
Name:TOOTELIAN, SOPHIE ANN
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:ANN
Last Name:TOOTELIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8334 N WADDAMS GROVE RD
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:IL
Mailing Address - Zip Code:61048-9750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8334 N WADDAMS GROVE RD
Practice Address - Street 2:
Practice Address - City:LENA
Practice Address - State:IL
Practice Address - Zip Code:61048-9750
Practice Address - Country:US
Practice Address - Phone:815-908-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide