Healthcare Provider Details

I. General information

NPI: 1922542034
Provider Name (Legal Business Name): MISS UFUOMA CHINENYE IDJESA SR.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: UFUOMA CHINENEYE IDJESA SR. RN

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N HOOKER ST STE 301
CHICAGO IL
60642-4633
US

IV. Provider business mailing address

1441 W FARWELL AVE APT 1F
CHICAGO IL
60626-6900
US

V. Phone/Fax

Practice location:
  • Phone: 312-943-3600
  • Fax: 312-943-3096
Mailing address:
  • Phone: 847-276-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number041393914
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: