=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306480025
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ONYEISI STEPHEN OGBOMEH DNP, APRN-FPA,FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2019
-----------------------------------------------------
Last Update Date | 07/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 CEDAR AVE
-----------------------------------------------------
City | LAKE VILLA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60046-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-844-3763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 CEDAR AVE
-----------------------------------------------------
City | LAKE VILLA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60046-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-791-2317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 209020388
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------