Healthcare Provider Details

I. General information

NPI: 1194576793
Provider Name (Legal Business Name): GRACE OSEIWE OBOH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WINDSOR RD
CHAMPAIGN IL
61822-6217
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-1200
  • Fax:
Mailing address:
  • Phone: 217-366-8130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209030000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: