Provider Demographics
NPI:1740915503
Name:OBONYO, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:OBONYO
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 1:1853 W POLK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4355
Mailing Address - Country:US
Mailing Address - Phone:443-207-1914
Mailing Address - Fax:
Practice Address - Street 1:1853 W POLK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4355
Practice Address - Country:US
Practice Address - Phone:443-207-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-17
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program