Healthcare Provider Details

I. General information

NPI: 1205651825
Provider Name (Legal Business Name): MICHAELA R KANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 E OAKLAND AVE STE B
BLOOMINGTON IL
61701-5783
US

IV. Provider business mailing address

208 WOODLAND AVE
BLOOMINGTON IL
61701-5660
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-3068
  • Fax:
Mailing address:
  • Phone: 815-671-5618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number209031048
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number209.031048
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209031048
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: