Provider Demographics
NPI:1013667898
Name:SANGOBANWO, MARIAM MOTUNRAYO (FNP)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:MOTUNRAYO
Last Name:SANGOBANWO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:MOTUNRAYO
Other - Last Name:ALAO ABOKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:500 W RAND RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-2360
Mailing Address - Country:US
Mailing Address - Phone:630-755-1754
Mailing Address - Fax:
Practice Address - Street 1:718 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3462
Practice Address - Country:US
Practice Address - Phone:630-755-1754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041467719163W00000X
IL209025140363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse