MEDICARE: PARAGON CITADEL LLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1700773819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARAGON CITADEL LLC

Provider Business Mailing Address
First Line	:	4951 S HUDSON PL
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85249-3168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4951 S HUDSON PL
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85249-3168
Country	:	US
Telephone Number	:	404-980-7137
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OLUWAKEMI OGUNLEYE
Credential	:
Telephone Number	:	214-646-1606

Provider Enumeration Date	:	06/20/2025
Last Update Date	:	06/25/2025

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Directions to “PARAGON CITADEL LLC ” Practice Location

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