Healthcare Provider Details

I. General information

NPI: 1629434741
Provider Name (Legal Business Name): VICTOR OKAMGBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 BOOK RD STE 103
NAPERVILLE IL
60567-1401
US

IV. Provider business mailing address

2709 WESTERN AVE
PARK FOREST IL
60466-1801
US

V. Phone/Fax

Practice location:
  • Phone: 708-873-9059
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013594
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: