Healthcare Provider Details

I. General information

NPI: 1770185852
Provider Name (Legal Business Name): MRS. FIDELIA UJUNWA ILEKA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 03/07/2026
Certification Date: 03/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 RIDGE RD STE 1
LANSING IL
60438-2792
US

IV. Provider business mailing address

2909 201ST PL
LYNWOOD IL
60411-1586
US

V. Phone/Fax

Practice location:
  • Phone: 708-699-7999
  • Fax:
Mailing address:
  • Phone: 708-699-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209022378
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041396430
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277004852
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: