MEDICARE: BONNAVENTURE I OGU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2025086017	IL

General Provider Information

NPI Number	:	1659220069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNAVENTURE I OGU

Provider Business Mailing Address
First Line	:	1906 LEE ST
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-1537
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4554 N BROADWAY ST STE 218
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5671
Country	:	US
Telephone Number	:	773-554-2490
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2026
Last Update Date	:	01/27/2026

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Directions to “ BONNAVENTURE I OGU ” Practice Location

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