Provider Demographics
NPI:1336993567
Name:SELLS, GRACE MIYOKO (CNM)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MIYOKO
Last Name:SELLS
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 1:2609 N DAYTON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6662
Mailing Address - Country:US
Mailing Address - Phone:408-348-8225
Mailing Address - Fax:
Practice Address - Street 1:7000 S COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-6973
Practice Address - Country:US
Practice Address - Phone:630-793-2676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029765367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife