Healthcare Provider Details

I. General information

NPI: 1013667898
Provider Name (Legal Business Name): MARIAM MOTUNRAYO SANGOBANWO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAM MOTUNRAYO ALAO ABOKO FNP

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 E NORTHWEST HWY
MOUNT PROSPECT IL
60056-3462
US

IV. Provider business mailing address

500 W RAND RD
ARLINGTON HEIGHTS IL
60004-2360
US

V. Phone/Fax

Practice location:
  • Phone: 630-755-1754
  • Fax:
Mailing address:
  • Phone: 630-755-1754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025140
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041467719
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: