Provider Demographics
NPI:1770185852
Name:ILEKA, FIDELIA UJUNWA
Entity Type:Individual
Prefix:MRS
First Name:FIDELIA
Middle Name:UJUNWA
Last Name:ILEKA
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 1:2909 201ST PL
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1586
Mailing Address - Country:US
Mailing Address - Phone:708-699-7999
Mailing Address - Fax:
Practice Address - Street 1:2521 RIDGE RD STE 1
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2792
Practice Address - Country:US
Practice Address - Phone:708-699-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041396430163WG0000X
IL209022378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice