Healthcare Provider Details

I. General information

NPI: 1467167635
Provider Name (Legal Business Name): GRACE OGUNNUBI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6758 N SHERIDAN RD APT 531
CHICAGO IL
60626-4434
US

IV. Provider business mailing address

6758 N SHERIDAN RD APT 531
CHICAGO IL
60626-4434
US

V. Phone/Fax

Practice location:
  • Phone: 773-571-0911
  • Fax:
Mailing address:
  • Phone: 773-571-0911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: