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NPI Code Detail

MEDICARE: OLALEKAN OLUMUYIWA FASOGBON PMHNP

MEDICARE: OLALEKAN OLUMUYIWA FASOGBON PMHNP
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner209.032300IL

General Provider Information

NPI Number : 1487442158
Entity Type Code : Individual
Provider Name (Legal Business Name) : OLALEKAN OLUMUYIWA FASOGBON PMHNP
Provider Business Mailing Address
First Line : 11724 S JUSTINE ST
Second Line :
City : CHICAGO
State : IL
Zip : 60643-5028
Country : US
Telephone Number : 773-419-0138
Fax Number :
Provider Business Practice Location Address
First Line : 10935 S HALSTED ST
Second Line :
City : CHICAGO
State : IL
Zip : 60628-3127
Country : US
Telephone Number : 773-419-0138
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/30/2025
Last Update Date : 08/13/2025

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