Provider Demographics
NPI:1497475461
Name:ISIJOLA, OLUBUNMI VICKI
Entity Type:Individual
Prefix:
First Name:OLUBUNMI
Middle Name:VICKI
Last Name:ISIJOLA
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 1:1923 E 172ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3727
Mailing Address - Country:US
Mailing Address - Phone:773-297-8374
Mailing Address - Fax:
Practice Address - Street 1:14484 JOHN HUMPHREY DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2638
Practice Address - Country:US
Practice Address - Phone:708-364-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041434818163WP0808X
IL209026319363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health