MEDICARE: MODUPE OJUETIMI OLUKEYE NURSE PRACTITIONER

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	163W00000X	Registered Nurse	041409665	IL
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209.023284	IL

General Provider Information

NPI Number	:	1295301315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MODUPE OJUETIMI OLUKEYE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	333 S STATE ST STE 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60604-3946
Country	:	US
Telephone Number	:	312-747-0036
Fax Number	:	312-747-2205

Provider Business Practice Location Address
First Line	:	2206 W GREENLEAF AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-4804
Country	:	US
Telephone Number	:	773-234-1067
Fax Number	:

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

Provider Enumeration Date	:	05/29/2021
Last Update Date	:	12/16/2025

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