Provider Demographics
NPI:1134546112
Name:ODUYALE, ALEXIS (APRN)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:ODUYALE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3918
Mailing Address - Country:US
Mailing Address - Phone:309-827-5351
Mailing Address - Fax:309-829-6808
Practice Address - Street 1:60 REVERE DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1590
Practice Address - Country:US
Practice Address - Phone:224-306-1879
Practice Address - Fax:224-306-1878
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023210363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health