Provider Demographics
NPI:1902360365
Name:BAKARE-ADEMOSU, ABOLORE GLORIA
Entity Type:Individual
Prefix:
First Name:ABOLORE
Middle Name:GLORIA
Last Name:BAKARE-ADEMOSU
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 1:3344 W PETERSON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3529
Mailing Address - Country:US
Mailing Address - Phone:773-831-1690
Mailing Address - Fax:
Practice Address - Street 1:3344 W PETERSON AVE STE 102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3529
Practice Address - Country:US
Practice Address - Phone:773-831-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018438363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily