Healthcare Provider Details

I. General information

NPI: 1912465303
Provider Name (Legal Business Name): KEHINDE CHRISTIANA FAGBEMI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E 45TH ST
CHICAGO IL
60653-3421
US

IV. Provider business mailing address

516 E 45TH ST
CHICAGO IL
60653-3421
US

V. Phone/Fax

Practice location:
  • Phone: 708-662-0493
  • Fax:
Mailing address:
  • Phone: 708-662-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018916
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209018916
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: