Provider Demographics
NPI:1952819054
Name:LOTT, SANDRA (CRNA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:LOTT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 N SHERIDAN RD APT 21A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1768
Mailing Address - Country:US
Mailing Address - Phone:225-241-5990
Mailing Address - Fax:225-241-5990
Practice Address - Street 1:1900 SILVER CROSS BLVD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9509
Practice Address - Country:US
Practice Address - Phone:225-241-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017089367500000X
GARN213687367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered