Provider Demographics
NPI:1639743107
Name:BOLADALE, OLADUNNI F
Entity Type:Individual
Prefix:
First Name:OLADUNNI
Middle Name:F
Last Name:BOLADALE
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 1:250 PARKWAY DR STE 150
Mailing Address - Street 2:
Mailing Address - City:LINCOLNSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60069-4340
Mailing Address - Country:US
Mailing Address - Phone:630-943-0412
Mailing Address - Fax:630-358-6841
Practice Address - Street 1:429 N WEBER RD
Practice Address - Street 2:STE B409
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-3902
Practice Address - Country:US
Practice Address - Phone:540-944-4000
Practice Address - Fax:540-944-4002
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023238363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health