Healthcare Provider Details

I. General information

NPI: 1699306902
Provider Name (Legal Business Name): IFE MUYIWA-OJO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 E CARPENTER ST
SPRINGFIELD IL
62702-5321
US

IV. Provider business mailing address

729 E CARPENTER ST
SPRINGFIELD IL
62702-5321
US

V. Phone/Fax

Practice location:
  • Phone: 217-725-0556
  • Fax:
Mailing address:
  • Phone: 217-725-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209020750
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: