Healthcare Provider Details

I. General information

NPI: 1073284477
Provider Name (Legal Business Name): HELEN T OWUSUAKOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 VALLEY VIEW LN STE 400
DALLAS TX
75244-5071
US

IV. Provider business mailing address

1637 FORDHAM ST
BOLINGBROOK IL
60490-5020
US

V. Phone/Fax

Practice location:
  • Phone: 972-715-3800
  • Fax:
Mailing address:
  • Phone: 312-227-5186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023649
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: