Provider Demographics
NPI:1134832512
Name:ADEFESO, MODUPE OLAYINKA (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MODUPE
Middle Name:OLAYINKA
Last Name:ADEFESO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3347 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60203-1722
Mailing Address - Country:US
Mailing Address - Phone:847-208-4457
Mailing Address - Fax:
Practice Address - Street 1:3347 CHURCH ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60203-1722
Practice Address - Country:US
Practice Address - Phone:847-208-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2022069013363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health