Healthcare Provider Details

I. General information

NPI: 1417789025
Provider Name (Legal Business Name): MICHAELA AMY WOLVERTON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE STE 424
CHICAGO IL
60602-3844
US

IV. Provider business mailing address

3209 N LAKEWOOD AVE
CHICAGO IL
60657-3215
US

V. Phone/Fax

Practice location:
  • Phone: 872-274-4344
  • Fax: 866-671-9991
Mailing address:
  • Phone: 872-274-4344
  • Fax: 866-671-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.033676
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number309.024591
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: