Provider Demographics
NPI:1376912758
Name:MITCHELL, KELSEY LEA (CNM)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LEA
Last Name:MITCHELL
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 1:5140 N CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3645
Mailing Address - Country:US
Mailing Address - Phone:773-989-6200
Mailing Address - Fax:773-989-6201
Practice Address - Street 1:5140 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3645
Practice Address - Country:US
Practice Address - Phone:773-989-6200
Practice Address - Fax:773-989-6201
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.396849163W00000X
IL209.013124367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse