Provider Demographics
NPI:1932675006
Name:IKERODAH, GLORY OBIANUJU (FNP)
Entity Type:Individual
Prefix:MRS
First Name:GLORY
Middle Name:OBIANUJU
Last Name:IKERODAH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2670
Mailing Address - Country:US
Mailing Address - Phone:877-692-8686
Mailing Address - Fax:815-937-0655
Practice Address - Street 1:1777 E COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2670
Practice Address - Country:US
Practice Address - Phone:773-676-4076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018155363L00000X
IL277.002987363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner