Provider Demographics
NPI:1124782123
Name:HENDERSON, LYNN (CNM)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N PARKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-3040
Mailing Address - Country:US
Mailing Address - Phone:773-295-3060
Mailing Address - Fax:773-295-3061
Practice Address - Street 1:115 N PARKSIDE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-3040
Practice Address - Country:US
Practice Address - Phone:773-295-3060
Practice Address - Fax:773-295-3061
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024227367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife