Healthcare Provider Details

I. General information

NPI: 1245103662
Provider Name (Legal Business Name): STELLA OGBONNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 W LAKE STREET
CHICAGO IL
60644
US

IV. Provider business mailing address

5461 W LAKE STREET
CHICAGO IL
60644
US

V. Phone/Fax

Practice location:
  • Phone: 773-378-3347
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209032796
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: