Healthcare Provider Details

I. General information

NPI: 1518557487
Provider Name (Legal Business Name): SAMSON OMOSHEWE OKOH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17843 TORRENCE AVE APT F
LANSING IL
60438-0197
US

IV. Provider business mailing address

17843 TORRENCE AVE APT F
LANSING IL
60438-0197
US

V. Phone/Fax

Practice location:
  • Phone: 773-941-2693
  • Fax:
Mailing address:
  • Phone: 773-941-2693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number363LPO808X
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: