Provider Demographics
NPI:1952317786
Name:MULCRONE, SANDRA LEE (CNM,APN,MS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:MULCRONE
Suffix:
Gender:F
Credentials:CNM,APN,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9635 S WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1613
Mailing Address - Country:US
Mailing Address - Phone:773-881-0228
Mailing Address - Fax:
Practice Address - Street 1:3048 N WILTON AVE FL 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6710
Practice Address - Country:US
Practice Address - Phone:773-296-3098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001535367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL41.254942Medicaid