Healthcare Provider Details

I. General information

NPI: 1790445708
Provider Name (Legal Business Name): MUTIAT KUFORIJI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2021
Last Update Date: 12/19/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21141 SOPHIA DR
MATTESON IL
60443-1869
US

IV. Provider business mailing address

21141 SOPHIA DR
MATTESON IL
60443-1869
US

V. Phone/Fax

Practice location:
  • Phone: 773-629-9754
  • Fax:
Mailing address:
  • Phone: 773-629-9754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041464352
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: