Healthcare Provider Details

I. General information

NPI: 1598677502
Provider Name (Legal Business Name): IMPECCABLE GRACE SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11724 S JUSTINE ST FL 1
CHICAGO IL
60643-5028
US

IV. Provider business mailing address

11724 S JUSTINE ST FL 1
CHICAGO IL
60643-5028
US

V. Phone/Fax

Practice location:
  • Phone: 773-419-0138
  • Fax: 619-984-4174
Mailing address:
  • Phone: 773-419-0138
  • Fax: 619-984-4174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. OLALEKAN OLUMUYIWA FASOGBON
Title or Position: NP
Credential: PMHNP-BC
Phone: 773-419-0138