=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801540216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADEREMI LAWAL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2022
-----------------------------------------------------
Last Update Date | 05/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1536 VINCENNES AVE
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-3458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-692-8686
-----------------------------------------------------
Fax | 708-754-2951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1536 VINCENNES AVE
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-3458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-692-8686
-----------------------------------------------------
Fax | 708-754-2051
-----------------------------------------------------
=====================================================
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 | 024569
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------