Healthcare Provider Details

I. General information

NPI: 1093628554
Provider Name (Legal Business Name): OLUCHI EZEMMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 GREEN BAY RD
NORTH CHICAGO IL
60064-3037
US

IV. Provider business mailing address

1100 N LA SALLE DR APT 520
CHICAGO IL
60610-2632
US

V. Phone/Fax

Practice location:
  • Phone: 847-578-3000
  • Fax:
Mailing address:
  • Phone: 401-330-7106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: