Provider Demographics
NPI:1174028021
Name:NUTAYI, OLUSEGUN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:
Last Name:NUTAYI
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 GOLF RD FL 12
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1224
Mailing Address - Country:US
Mailing Address - Phone:888-215-8756
Mailing Address - Fax:
Practice Address - Street 1:4711 GOLF RD FL 12
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1224
Practice Address - Country:US
Practice Address - Phone:888-215-8756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty