Provider Demographics
NPI:1396469730
Name:MORTENSEN-WARD, KRISTIN MARIE (CPM, LM CPM, LCPM)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:MORTENSEN-WARD
Suffix:
Gender:F
Credentials:CPM, LM CPM, LCPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:IL
Mailing Address - Zip Code:61252-9619
Mailing Address - Country:US
Mailing Address - Phone:309-507-2420
Mailing Address - Fax:
Practice Address - Street 1:14100 KENNEDY RD
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:IL
Practice Address - Zip Code:61252-9619
Practice Address - Country:US
Practice Address - Phone:309-507-2420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175M00000X
WI528-49176B00000X
ILCPM0003176B00000X
IL295.000022176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No175M00000XOther Service ProvidersMidwife, Lay