Provider Demographics
NPI:1669566782
Name:POPE-OSAGHAE, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:POPE-OSAGHAE
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 1:17359 S MCKENNA DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-9292
Mailing Address - Country:US
Mailing Address - Phone:708-741-2325
Mailing Address - Fax:
Practice Address - Street 1:1333 SCHOOLHOUSE RD
Practice Address - Street 2:SUITE #109
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451
Practice Address - Country:US
Practice Address - Phone:708-741-2325
Practice Address - Fax:484-351-3800
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004787363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ20789Medicare UPIN