Provider Demographics
NPI:1689389629
Name:ADEYEMI, OMOLOLA
Entity Type:Individual
Prefix:
First Name:OMOLOLA
Middle Name:
Last Name:ADEYEMI
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 1:23035 ANNA LN
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423
Mailing Address - Country:US
Mailing Address - Phone:708-382-1659
Mailing Address - Fax:
Practice Address - Street 1:1 TIFFANY PT STE 110
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2915
Practice Address - Country:US
Practice Address - Phone:708-382-1659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026543363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health