Healthcare Provider Details

I. General information

NPI: 1124782123
Provider Name (Legal Business Name): LYNN HENDERSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N PARKSIDE AVE
CHICAGO IL
60644-3040
US

IV. Provider business mailing address

115 N PARKSIDE AVE
CHICAGO IL
60644-3040
US

V. Phone/Fax

Practice location:
  • Phone: 773-295-3060
  • Fax: 773-295-3061
Mailing address:
  • Phone: 773-295-3060
  • Fax: 773-295-3061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209024227
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: