Healthcare Provider Details

I. General information

NPI: 1093050841
Provider Name (Legal Business Name): EBELE N ILOABACHIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MARKET PL STE 100
FAIRVIEW HEIGHTS IL
62208-2089
US

IV. Provider business mailing address

7006 STONY RIDGE RD
SAINT LOUIS MO
63129-6405
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-4226
  • Fax: 618-398-1759
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.010250
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2021048982
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2012036151
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277003973
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: