Healthcare Provider Details

I. General information

NPI: 1134887623
Provider Name (Legal Business Name): RUKAYAT OMOLABI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9718 S HALSTED ST
CHICAGO IL
60628-1007
US

IV. Provider business mailing address

6821 S HALSTED ST
CHICAGO IL
60621-1833
US

V. Phone/Fax

Practice location:
  • Phone: 773-233-4100
  • Fax: 773-344-3158
Mailing address:
  • Phone: 312-307-0978
  • Fax: 773-344-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209024372
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: