Provider Demographics
NPI:1871049635
Name:DETHMERS, TARA JANE (APRN, CNM)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:JANE
Last Name:DETHMERS
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR STE 815
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4449
Mailing Address - Country:US
Mailing Address - Phone:312-926-5521
Mailing Address - Fax:312-926-8855
Practice Address - Street 1:680 N LAKE SHORE DR STE 815
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4449
Practice Address - Country:US
Practice Address - Phone:312-926-5521
Practice Address - Fax:312-926-8855
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014778367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife