Healthcare Provider Details

I. General information

NPI: 1609412410
Provider Name (Legal Business Name): OLALEKAN MOSES FAPOHUNDA DNP, APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 159TH ST
TINLEY PARK IL
60477-1758
US

IV. Provider business mailing address

6701 159TH ST
TINLEY PARK IL
60477-1758
US

V. Phone/Fax

Practice location:
  • Phone: 708-429-3300
  • Fax:
Mailing address:
  • Phone: 708-798-9475
  • Fax: 708-798-9485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.433033
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.023658
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: