Healthcare Provider Details

I. General information

NPI: 1235563537
Provider Name (Legal Business Name): ABIGAIL UGOAGHA OGUNNIYI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4363 MAPLE TER
COUNTRY CLUB HILLS IL
60478-5541
US

IV. Provider business mailing address

50 S B B KING BLVD
MEMPHIS TN
38103-2626
US

V. Phone/Fax

Practice location:
  • Phone: 773-440-1368
  • Fax:
Mailing address:
  • Phone: 866-949-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.010627
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277000463
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: