Healthcare Provider Details

I. General information

NPI: 1952212474
Provider Name (Legal Business Name): NOSAMUDIANA W ODIASE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 N MARINE DR
CHICAGO IL
60640-7860
US

IV. Provider business mailing address

16058 S DANA DR
PLAINFIELD IL
60586-1031
US

V. Phone/Fax

Practice location:
  • Phone: 215-406-5470
  • Fax:
Mailing address:
  • Phone: 215-406-5470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2026080040
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: