=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841836558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERYL AGBONGHAE NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2019
-----------------------------------------------------
Last Update Date | 10/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5336 N WESTERN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-231-3162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 74008272
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60674-8272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-899-0595
-----------------------------------------------------
Fax | 702-977-1496
-----------------------------------------------------
=====================================================
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 | 209019429
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------