Provider Demographics
NPI:1528216082
Name:MIKULICH, SANDRA LYNN (APN)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LYNN
Last Name:MIKULICH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:17850 KEDZIE AVE STE 3250
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2082
Practice Address - Country:US
Practice Address - Phone:708-799-8700
Practice Address - Fax:708-957-1830
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007221363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3160176976OtherBLUE CROSS
ILCM7411OtherRAILROAD MEDICARE
ILP00694835OtherRAILROAD MEDICARE
IL3160176976OtherBLUE CROSS
ILCM7411OtherRAILROAD MEDICARE
IL594180Medicare PIN