Healthcare Provider Details

I. General information

NPI: 1306480025
Provider Name (Legal Business Name): ONYEISI STEPHEN OGBOMEH DNP, APRN-FPA,FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 CEDAR AVE
LAKE VILLA IL
60046-4600
US

IV. Provider business mailing address

206 CEDAR AVE
LAKE VILLA IL
60046-4600
US

V. Phone/Fax

Practice location:
  • Phone: 224-844-3763
  • Fax:
Mailing address:
  • Phone: 773-791-2317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209020388
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: