Healthcare Provider Details

I. General information

NPI: 1962799007
Provider Name (Legal Business Name): ADEOLA O ADESUYI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 W DIVISION ST
CHICAGO IL
60622-8151
US

IV. Provider business mailing address

3853 BRUMMEL ST
SKOKIE IL
60076-3625
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2000
  • Fax:
Mailing address:
  • Phone: 847-722-6519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209008779
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: