Provider Demographics
NPI:1336809326
Name:MARSHALL, DEBORAH MOFOLUWA
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:MOFOLUWA
Last Name:MARSHALL
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 1:1085 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1319
Mailing Address - Country:US
Mailing Address - Phone:815-662-7436
Mailing Address - Fax:
Practice Address - Street 1:500 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3661
Practice Address - Country:US
Practice Address - Phone:815-937-2121
Practice Address - Fax:815-928-6211
Is Sole Proprietor?:No
Enumeration Date:2021-12-18
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.024576363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily