Healthcare Provider Details

I. General information

NPI: 1770177636
Provider Name (Legal Business Name): MONDAY OGBEIBOR NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N BURR BLVD
KEWANEE IL
61443-8377
US

IV. Provider business mailing address

501 PINE KNOLL CIR
BATTLE CREEK MI
49014-7725
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-0197
  • Fax:
Mailing address:
  • Phone: 269-419-1701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704321230
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: