MEDICARE: MUTIATU MODUPE MOIBI

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209030990	IL

General Provider Information

NPI Number	:	1831999176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MUTIATU MODUPE MOIBI

Provider Business Mailing Address
First Line	:	5336 DAVIS ST
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-1535
Country	:	US
Telephone Number	:	773-615-6099
Fax Number	:

Provider Business Practice Location Address
First Line	:	4621 N RACINE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-4905
Country	:	US
Telephone Number	:	773-784-2300
Fax Number	:

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

Provider Enumeration Date	:	03/17/2025
Last Update Date	:	03/17/2025

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Directions to “ MUTIATU MODUPE MOIBI ” Practice Location

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