=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174028021
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLUSEGUN NUTAYI DNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2018
-----------------------------------------------------
Last Update Date | 07/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1431 OPUS PL STE 110
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-1164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-895-2051
-----------------------------------------------------
Fax | 630-331-9960
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1431 OPUS PL STE 110
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-1164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-895-2051
-----------------------------------------------------
Fax | 630-331-9960
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209017378
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------