Provider Demographics
NPI:1255689188
Name:ADEMOYO, ADENIYI C (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ADENIYI
Middle Name:C
Last Name:ADEMOYO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 ARROWHEAD ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1437
Mailing Address - Country:US
Mailing Address - Phone:630-874-2542
Mailing Address - Fax:630-874-2642
Practice Address - Street 1:3701 DOTY ROAD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098
Practice Address - Country:US
Practice Address - Phone:630-874-2542
Practice Address - Fax:630-874-2642
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009720367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered