Healthcare Provider Details

I. General information

NPI: 1992425409
Provider Name (Legal Business Name): CHARLOTTE NOUGOUAPI PAULINE DJOMGOUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2714
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number041412436
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209025824
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209025824
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: