Provider Demographics
NPI:1194887356
Name:WILLEN, AMY ELIZABETH (CNM)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:WILLEN
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 1:3225 W PIERCE AVE
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-2454
Mailing Address - Country:US
Mailing Address - Phone:713-569-5997
Mailing Address - Fax:
Practice Address - Street 1:715 LAKE ST
Practice Address - Street 2:SUITE 273
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1422
Practice Address - Country:US
Practice Address - Phone:708-848-3800
Practice Address - Fax:708-848-0008
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2012-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX712808367A00000X
IL209.006855367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175342802Medicaid
TX175342802Medicaid
IL$$$$$$$$$001Medicaid
TX175342802Medicaid