Provider Demographics
NPI:1700599248
Name:AGBAJE, OREOLUWATOMI (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:OREOLUWATOMI
Middle Name:
Last Name:AGBAJE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 N HALSTED ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-0877
Mailing Address - Country:US
Mailing Address - Phone:773-699-4924
Mailing Address - Fax:
Practice Address - Street 1:2707 N HALSTED ST STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-0877
Practice Address - Country:US
Practice Address - Phone:773-699-4924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026038363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health