Healthcare Provider Details

I. General information

NPI: 1720968415
Provider Name (Legal Business Name): MOKITA WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6533 S COTTAGE GROVE AVE
CHICAGO IL
60637-4209
US

IV. Provider business mailing address

6533 S COTTAGE GROVE AVE
CHICAGO IL
60637-4209
US

V. Phone/Fax

Practice location:
  • Phone: 708-769-4062
  • Fax:
Mailing address:
  • Phone: 708-769-4062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TIKITA MAHAN
Title or Position: OWNER
Credential: RN
Phone: 708-769-4062