Provider Demographics
NPI:1942759048
Name:FELICIANO, SOPHIA
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:FELICIANO
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 1:12216 W THOMAS CT
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12216 W THOMAS CT
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9435
Practice Address - Country:US
Practice Address - Phone:708-645-4580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.072024164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse