Healthcare Provider Details

I. General information

NPI: 1740914910
Provider Name (Legal Business Name): MAWUSI YAWA KUDJAWU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 S EOLA RD
AURORA IL
60503-6485
US

IV. Provider business mailing address

2211 S EOLA RD # 4262
AURORA IL
60503-6485
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025097
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: