Healthcare Provider Details

I. General information

NPI: 1710492947
Provider Name (Legal Business Name): MARY LEUNG CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SUPERIOR ST STE 101
MELROSE PARK IL
60160
US

IV. Provider business mailing address

1111 SUPERIOR ST STE 101
MELROSE PARK IL
60160-4100
US

V. Phone/Fax

Practice location:
  • Phone: 708-406-3040
  • Fax: 708-406-3059
Mailing address:
  • Phone: 708-406-3040
  • Fax: 708-406-3059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.421334
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209.016167
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: