Provider Demographics
NPI:1003280090
Name:FATUGA, MOPELOLA O
Entity Type:Individual
Prefix:MRS
First Name:MOPELOLA
Middle Name:O
Last Name:FATUGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HEATHROW CT
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7774
Mailing Address - Country:US
Mailing Address - Phone:312-523-4742
Mailing Address - Fax:630-752-0980
Practice Address - Street 1:1005 HEATHROW CT
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-7774
Practice Address - Country:US
Practice Address - Phone:312-523-4742
Practice Address - Fax:630-752-0980
Is Sole Proprietor?:No
Enumeration Date:2015-11-14
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL400449163W00000X
IL1011561163WH0200X
IL3001137376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12HH017Medicare PIN