Healthcare Provider Details

I. General information

NPI: 1205605235
Provider Name (Legal Business Name): ABIDEMI BALOGUN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N 2ND ST
MARSHALL IL
62441-1010
US

IV. Provider business mailing address

1372 FARGO AVE APT B
DES PLAINES IL
60018-2991
US

V. Phone/Fax

Practice location:
  • Phone: 718-506-1115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209028750
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: