Provider Demographics
NPI:1225305246
Name:WAGALA-AYAFOR, INNOCENTCIA
Entity Type:Individual
Prefix:
First Name:INNOCENTCIA
Middle Name:
Last Name:WAGALA-AYAFOR
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 1:2650 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-4710
Mailing Address - Fax:
Practice Address - Street 1:1776 CAMDEN DR
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7616
Practice Address - Country:US
Practice Address - Phone:847-832-9821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-002320363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner