Healthcare Provider Details

I. General information

NPI: 1336859131
Provider Name (Legal Business Name): PHILOMENA OKONKWO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

20101 CATALPA AVE
LYNWOOD IL
60411-6806
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-5066
  • Fax:
Mailing address:
  • Phone: 708-362-7106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025321
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: