Provider Demographics
NPI:1205651825
Name:KANE, MICHAELA R
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:R
Last Name:KANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5660
Mailing Address - Country:US
Mailing Address - Phone:815-671-5618
Mailing Address - Fax:
Practice Address - Street 1:2111 E OAKLAND AVE STE B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5783
Practice Address - Country:US
Practice Address - Phone:309-808-3068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209031048163WX0003X, 367A00000X
IL209.031048176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
No176B00000XOther Service ProvidersMidwife