Provider Demographics
NPI:1558996942
Name:KOUGBANI-SEBOU, MARCELINE (APN)
Entity Type:Individual
Prefix:MRS
First Name:MARCELINE
Middle Name:
Last Name:KOUGBANI-SEBOU
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SILVIS
Mailing Address - State:IL
Mailing Address - Zip Code:61282-4701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 ILLINI DR
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-1804
Practice Address - Country:US
Practice Address - Phone:309-281-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020857363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily