Healthcare Provider Details

I. General information

NPI: 1366267056
Provider Name (Legal Business Name): OMOLOLA WASILAT ANIMASHAUN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TIFFANY PT STE 105
BLOOMINGDALE IL
60108-2915
US

IV. Provider business mailing address

741 TREELINE DR
ALGONQUIN IL
60102-4326
US

V. Phone/Fax

Practice location:
  • Phone: 630-980-1400
  • Fax:
Mailing address:
  • Phone: 708-271-2171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209031077
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: