Provider Demographics
NPI:1205605235
Name:BALOGUN, ABIDEMI (PMHNP)
Entity type:Individual
Prefix:
First Name:ABIDEMI
Middle Name:
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 FARGO AVE APT B
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-2991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:IL
Practice Address - Zip Code:62441-1010
Practice Address - Country:US
Practice Address - Phone:718-506-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028750363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty