Healthcare Provider Details

I. General information

NPI: 1700640059
Provider Name (Legal Business Name): DEBORAH O OLUDEMI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15601 CICERO AVE SUITE 103E
OAK FOREST IL
60452-3635
US

IV. Provider business mailing address

15601 CICERO AVE STE 103E
OAK FOREST IL
60452-3636
US

V. Phone/Fax

Practice location:
  • Phone: 708-722-2329
  • Fax: 708-444-4960
Mailing address:
  • Phone: 708-722-2329
  • Fax: 708-444-4960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209026383
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209026383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: