MEDICARE: ABOLORE GLORIA BAKARE-ADEMOSU

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	209018438	IL

General Provider Information

NPI Number	:	1902360365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABOLORE GLORIA BAKARE-ADEMOSU

Provider Business Mailing Address
First Line	:	3344 W PETERSON AVE STE 102
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3529
Country	:	US
Telephone Number	:	773-831-1690
Fax Number	:

Provider Business Practice Location Address
First Line	:	3344 W PETERSON AVE STE 102
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3529
Country	:	US
Telephone Number	:	773-831-1690
Fax Number	:

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

Provider Enumeration Date	:	01/29/2019
Last Update Date	:	08/02/2019

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