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NPI Code Detail

MEDICARE: MRS. DEHEDGRA IDOWU AGPCNP-BC

MEDICARE: MRS. DEHEDGRA IDOWU AGPCNP-BC
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
1163W00000XRegistered NurseRN562570PA
2363LG0600XGerontology Nurse Practitioner209012233IL
3163WM0705XMedical-Surgical Registered Nurse041424181IL

General Provider Information

NPI Number : 1609054881
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. DEHEDGRA IDOWU AGPCNP-BC
Provider Business Mailing Address
First Line : 213 N RACINE AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60607-1644
Country : US
Telephone Number : 312-733-9730
Fax Number :
Provider Business Practice Location Address
First Line : 18 CHICAGO AVE
Second Line :
City : OAK PARK
State : IL
Zip : 60302-2402
Country : US
Telephone Number : 773-253-3933
Fax Number : 773-437-6780
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/09/2008
Last Update Date : 10/15/2015

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