Healthcare Provider Details

I. General information

NPI: 1295301315
Provider Name (Legal Business Name): MODUPE OJUETIMI OLUKEYE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MODUPE O OSUNKEYE OSUNKEYE

II. Dates (important events)

Enumeration Date: 05/29/2021
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2206 W GREENLEAF AVE
CHICAGO IL
60645-4804
US

IV. Provider business mailing address

333 S STATE ST STE 200
CHICAGO IL
60604-3946
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-1067
  • Fax:
Mailing address:
  • Phone: 312-747-0036
  • Fax: 312-747-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041409665
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.023284
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: