Healthcare Provider Details

I. General information

NPI: 1255814679
Provider Name (Legal Business Name): MICHELLE RENEE DORMANEN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE RENEE SORENSEN

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 W OGDEN AVE
CHICAGO IL
60608
US

IV. Provider business mailing address

1500 S. FAIRFIELD AVE
CHICAGO IL
60608
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6508
  • Fax:
Mailing address:
  • Phone: 737-257-6691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number041.431303
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM04289
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: