Provider Demographics
NPI:1295301315
Name:OLUKEYE, MODUPE O (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MODUPE
Middle Name:O
Last Name:OLUKEYE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:MODUPE
Other - Middle Name:O
Other - Last Name:OSUNKEYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OSUNKEYE
Mailing Address - Street 1:333 S STATE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3946
Mailing Address - Country:US
Mailing Address - Phone:312-747-0036
Mailing Address - Fax:312-747-2205
Practice Address - Street 1:2525 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2315
Practice Address - Country:US
Practice Address - Phone:773-564-3882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041409665163W00000X
IL209.023284363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse