Provider Demographics
NPI:1831999176
Name:MOIBI, MUTIATU MODUPE
Entity type:Individual
Prefix:
First Name:MUTIATU
Middle Name:MODUPE
Last Name:MOIBI
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 1:5336 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1535
Mailing Address - Country:US
Mailing Address - Phone:773-615-6099
Mailing Address - Fax:
Practice Address - Street 1:4621 N RACINE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4905
Practice Address - Country:US
Practice Address - Phone:773-784-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030990363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health