Provider Demographics
NPI:1407855919
Name:KRUEGER, MARLA C (CNM)
Entity Type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:C
Last Name:KRUEGER
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 1:1800 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3112
Mailing Address - Country:US
Mailing Address - Phone:630-653-4240
Mailing Address - Fax:630-315-6557
Practice Address - Street 1:1800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3112
Practice Address - Country:US
Practice Address - Phone:630-653-4240
Practice Address - Fax:630-315-6557
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000624367A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001OtherMEDICAID
IL201737Medicare PIN
IL$$$$$$$$$001OtherMEDICAID
IL201986Medicare ID - Type Unspecified