Provider Demographics
NPI:1982214144
Name:EREBHOLO, ADEBIMPE FAVOUR (NP)
Entity Type:Individual
Prefix:
First Name:ADEBIMPE
Middle Name:FAVOUR
Last Name:EREBHOLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1562
Mailing Address - Country:US
Mailing Address - Phone:309-698-8300
Mailing Address - Fax:309-698-8303
Practice Address - Street 1:3300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-1562
Practice Address - Country:US
Practice Address - Phone:309-698-8300
Practice Address - Fax:309-698-8303
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041434445163WN0300X
IL209022026363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WN0300XNursing Service ProvidersRegistered NurseNephrology