=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780449256
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE OLATUNJI DNP, APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2024
-----------------------------------------------------
Last Update Date | 02/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3752 W 16TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-762-2435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 N MARINE DR APT 10B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-6355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-997-9642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 209.029118
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------