Provider Demographics
NPI:1700554904
Name:SOTELO, SIERRA NICOLE BUSHMAN
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:NICOLE BUSHMAN
Last Name:SOTELO
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 1:1750 N MARYWOOD AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505-1564
Mailing Address - Country:US
Mailing Address - Phone:815-631-1773
Mailing Address - Fax:
Practice Address - Street 1:1750 N MARYWOOD AVE APT 211
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-1564
Practice Address - Country:US
Practice Address - Phone:815-631-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program