Provider Demographics
NPI:1336715978
Name:EKONG, ANIEMA
Entity Type:Individual
Prefix:
First Name:ANIEMA
Middle Name:
Last Name:EKONG
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 1:4533 ARBORVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532
Mailing Address - Country:US
Mailing Address - Phone:630-995-1936
Mailing Address - Fax:
Practice Address - Street 1:4533 ARBORVIEW DR
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532
Practice Address - Country:US
Practice Address - Phone:630-995-1936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023313363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.023313OtherIDFPR