Healthcare Provider Details

I. General information

NPI: 1619747219
Provider Name (Legal Business Name): BOLATITO OLUBUKOLA OGUNSANWO APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 DOTY RD
WOODSTOCK IL
60098-7530
US

IV. Provider business mailing address

3707 DOTY RD
WOODSTOCK IL
60098-7530
US

V. Phone/Fax

Practice location:
  • Phone: 815-334-5018
  • Fax: 815-206-2822
Mailing address:
  • Phone: 815-334-5018
  • Fax: 815-206-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.028763
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209028763
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: