Provider Demographics
NPI:1619179041
Name:DANMOLE-ODIMAYO, OMOTOLA WASILAT (FNP-BC, DNP)
Entity Type:Individual
Prefix:DR
First Name:OMOTOLA
Middle Name:WASILAT
Last Name:DANMOLE-ODIMAYO
Suffix:
Gender:F
Credentials:FNP-BC, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7011 PRESTON DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-4310
Mailing Address - Country:US
Mailing Address - Phone:217-553-0266
Mailing Address - Fax:
Practice Address - Street 1:5850 6TH STREET FRONTAGE RD E STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5194
Practice Address - Country:US
Practice Address - Phone:217-529-5046
Practice Address - Fax:217-529-6154
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.006961363LF0000X, 364SF0001X
IL041-306705163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health