Provider Demographics
NPI:1245826544
Name:AGBO ATCHON, AKUVI AKPEDZE DIDI
Entity type:Individual
Prefix:
First Name:AKUVI
Middle Name:AKPEDZE DIDI
Last Name:AGBO ATCHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 O'HAGAN DR
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307
Mailing Address - Country:US
Mailing Address - Phone:312-203-6788
Mailing Address - Fax:
Practice Address - Street 1:650 GRANT ST STE 7
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46404-1551
Practice Address - Country:US
Practice Address - Phone:219-882-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022525363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily