Provider Demographics
NPI:1114675311
Name:ANICHEBE, VICTORIA NGOZI
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:NGOZI
Last Name:ANICHEBE
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 1:2415 W BIRCHWOOD AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9600 GROSS POINT RD STE 1200
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1214
Practice Address - Country:US
Practice Address - Phone:847-866-7846
Practice Address - Fax:224-241-5089
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085008780363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant