Provider Demographics
NPI:1154616928
Name:SANDRIK, MARY SUSAN (MSN, RN, CWOCN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:SANDRIK
Suffix:
Gender:F
Credentials:MSN, RN, CWOCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2248 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2201
Mailing Address - Country:US
Mailing Address - Phone:708-788-7340
Mailing Address - Fax:
Practice Address - Street 1:1500 SOUTH CALIFORNIA AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:773-542-2000
Practice Address - Fax:773-257-5205
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL309.000463364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist