Healthcare Provider Details

I. General information

NPI: 1891198628
Provider Name (Legal Business Name): EVELYN UKPOLO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 S BOLINGBROOK DR
BOLINGBROOK IL
60440-2852
US

IV. Provider business mailing address

217 CHRISTINE WAY
BOLINGBROOK IL
60440-6138
US

V. Phone/Fax

Practice location:
  • Phone: 630-914-5373
  • Fax:
Mailing address:
  • Phone: 773-540-6231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277003205
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: