=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205605235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIDEMI BALOGUN PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2024
-----------------------------------------------------
Last Update Date | 01/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 N 2ND ST
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62441-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-506-1115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1372 FARGO AVE APT B
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60018-2991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 209028750
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------