MEDICARE: TARA JANE DETHMERS APRN, CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367A00000X	Advanced Practice Midwife	209014778	IL

General Provider Information

NPI Number	:	1871049635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA JANE DETHMERS APRN, CNM

Provider Business Mailing Address
First Line	:	680 N LAKE SHORE DR STE 815
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4449
Country	:	US
Telephone Number	:	312-926-5521
Fax Number	:	312-926-8855

Provider Business Practice Location Address
First Line	:	680 N LAKE SHORE DR STE 815
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4449
Country	:	US
Telephone Number	:	312-926-5521
Fax Number	:	312-926-8855

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	07/12/2024

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