Provider Demographics
NPI:1063900603
Name:ODEFADEHAN, ADEWUMI C (APRN-FPA)
Entity type:Individual
Prefix:
First Name:ADEWUMI
Middle Name:C
Last Name:ODEFADEHAN
Suffix:
Gender:M
Credentials:APRN-FPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3144
Mailing Address - Country:US
Mailing Address - Phone:847-787-3734
Mailing Address - Fax:630-451-9896
Practice Address - Street 1:1005 S EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-3144
Practice Address - Country:US
Practice Address - Phone:847-787-3734
Practice Address - Fax:630-451-9896
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017467363LF0000X, 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
IL1063900603Medicaid