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General NPI Number Information
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NPI Number | 1487442158
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Entity Type | Individual
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Provider Name | OLALEKAN OLUMUYIWA FASOGBON PMHNP
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Gender | Male
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Dates
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Enumeration Date | 04/30/2025
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Last Update Date | 08/13/2025
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Provider Practice Location Address
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Address Line | 10935 S HALSTED ST
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City | CHICAGO
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State | IL
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Zip | 60628-3127
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Country | US
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Telephone | 773-419-0138
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Fax |
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Provider Business Mailing Address
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Address Line | 11724 S JUSTINE ST
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City | CHICAGO
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State | IL
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Zip | 60643-5028
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Country | US
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Telephone | 773-419-0138
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 209.032300
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License Number State | IL
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