Healthcare Provider Details

I. General information

NPI: 1922890904
Provider Name (Legal Business Name): IBUKUN AYODEJI DUROSANYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9964 HOLLY LN APT 2N
DES PLAINES IL
60016-1416
US

IV. Provider business mailing address

9964 HOLLY LN APT 2N
DES PLAINES IL
60016-1416
US

V. Phone/Fax

Practice location:
  • Phone: 779-777-4174
  • Fax:
Mailing address:
  • Phone: 779-777-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number041572103
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number041572103
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041572103
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number041572103
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: