Provider Demographics
NPI:1619531753
Name:IDOWU, SULIYAT
Entity Type:Individual
Prefix:
First Name:SULIYAT
Middle Name:
Last Name:IDOWU
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 1:16413 BETTY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2215
Mailing Address - Country:US
Mailing Address - Phone:708-953-5356
Mailing Address - Fax:
Practice Address - Street 1:16413 BETTY LN
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2215
Practice Address - Country:US
Practice Address - Phone:708-953-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.389857163W00000X
IL209.018571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse