Provider Demographics
NPI:1649052184
Name:SULAIMAN, IBRAHIM OLAWALE
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:OLAWALE
Last Name:SULAIMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-1006
Mailing Address - Country:US
Mailing Address - Phone:312-623-6048
Mailing Address - Fax:
Practice Address - Street 1:3515 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-1006
Practice Address - Country:US
Practice Address - Phone:312-623-6048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028476363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health