Healthcare Provider Details

I. General information

NPI: 1134846124
Provider Name (Legal Business Name): CHRISTIANA OTUWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 WYSTERIA DR
OLYMPIA FLDS IL
60461-1228
US

IV. Provider business mailing address

504 WYSTERIA DR
OLYMPIA FLDS IL
60461-1228
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax: 312-864-7294
Mailing address:
  • Phone: 708-955-6204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAG05220029
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: