Healthcare Provider Details

I. General information

NPI: 1174282826
Provider Name (Legal Business Name): IDAYATU OLA OMONIYI APRN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IDAYATU OLA OMONIYI PMHNP-BC

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7060 CENTENNIAL DR STE 102B
TINLEY PARK IL
60477-1699
US

IV. Provider business mailing address

7060 CENTENNIAL DR STE 102B
TINLEY PARK IL
60477-1699
US

V. Phone/Fax

Practice location:
  • Phone: 708-575-8043
  • Fax: 708-575-7872
Mailing address:
  • Phone: 708-575-8043
  • Fax: 708-575-7872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209024507
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number209.024507
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number277003719
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: