Provider Demographics
NPI:1558787960
Name:AMIYAN, MOFOLUWA
Entity Type:Individual
Prefix:
First Name:MOFOLUWA
Middle Name:
Last Name:AMIYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOFOLUWA
Other - Middle Name:
Other - Last Name:AMIYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:4512 JEFFERSON DR
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1852
Mailing Address - Country:US
Mailing Address - Phone:708-244-7449
Mailing Address - Fax:
Practice Address - Street 1:4512 JEFFERSON DR
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1852
Practice Address - Country:US
Practice Address - Phone:708-244-7449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011157363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213401409214100Medicaid