MEDICARE: AKUVI AKPEDZE DIDI AGBO ATCHON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209.022525	IL

General Provider Information

NPI Number	:	1245826544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AKUVI AKPEDZE DIDI AGBO ATCHON

Provider Business Mailing Address
First Line	:	479 O'HAGAN DR
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307
Country	:	US
Telephone Number	:	312-203-6788
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 GRANT ST STE 7
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46404-1551
Country	:	US
Telephone Number	:	219-882-9900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2020
Last Update Date	:	12/02/2021

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