Provider Demographics
NPI:1649514316
Name:FORSTER IVY, KELLY KATHLEEN (CNM, WHNP-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHLEEN
Last Name:FORSTER IVY
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:KATHLEEN
Other - Last Name:FORSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 N WESTMORELAND RD STE 112
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045
Mailing Address - Country:US
Mailing Address - Phone:847-535-7057
Mailing Address - Fax:847-615-2260
Practice Address - Street 1:900 N WESTMORELAND RD STE 112
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045
Practice Address - Country:US
Practice Address - Phone:847-535-7057
Practice Address - Fax:847-615-2260
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009824367A00000X
IL277001068363L00000X
IL041369474163WX0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209010141OtherSTATE LICENSE