Healthcare Provider Details

I. General information

NPI: 1598202897
Provider Name (Legal Business Name): FADESIRE O AJUWON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 S KING DR 1N
CHICAGO IL
60653
US

IV. Provider business mailing address

355 E ERIE ST
CHICAGO IL
60611-3167
US

V. Phone/Fax

Practice location:
  • Phone: 708-705-5841
  • Fax: 773-751-2250
Mailing address:
  • Phone: 312-238-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-014405
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number209014405
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: