Healthcare Provider Details

I. General information

NPI: 1609279819
Provider Name (Legal Business Name): GRACE GAR YUN LARSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 03/07/2023
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE
CHICAGO IL
60623-8400
US

IV. Provider business mailing address

3860 W OGDEN AVE
CHICAGO IL
60623-8400
US

V. Phone/Fax

Practice location:
  • Phone: 872-588-3000
  • Fax:
Mailing address:
  • Phone: 872-588-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209011927
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041374899
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number209011927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: