Healthcare Provider Details

I. General information

NPI: 1891591194
Provider Name (Legal Business Name): IJEOMA AUGUSTINA UKACHUKWU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 COLUMBIA LN
GILBERTS IL
60136-8021
US

IV. Provider business mailing address

425 COLUMBIA LN
GILBERTS IL
60136-8021
US

V. Phone/Fax

Practice location:
  • Phone: 630-338-6781
  • Fax:
Mailing address:
  • Phone: 630-338-6781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.030145
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: