Healthcare Provider Details

I. General information

NPI: 1760316954
Provider Name (Legal Business Name): ABIMBOLA ABANNI MOMODU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E LAKE AVE
GLENVIEW IL
60025-2003
US

IV. Provider business mailing address

9700 DEE RD APT 204
DES PLAINES IL
60016-1733
US

V. Phone/Fax

Practice location:
  • Phone: 847-729-1300
  • Fax:
Mailing address:
  • Phone: 773-879-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209035731
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: