Healthcare Provider Details

I. General information

NPI: 1396469730
Provider Name (Legal Business Name): KRISTIN MARIE MORTENSEN-WARD CPM, LM CPM, LCPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 KENNEDY RD
FULTON IL
61252-9619
US

IV. Provider business mailing address

14100 KENNEDY RD
FULTON IL
61252-9619
US

V. Phone/Fax

Practice location:
  • Phone: 309-507-2420
  • Fax:
Mailing address:
  • Phone: 309-507-2420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number528-49
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCPM0003
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number295.000022
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: