Provider Demographics
NPI:1124670948
Name:ADEAGBO, BUKOLA EUNICE
Entity type:Individual
Prefix:
First Name:BUKOLA
Middle Name:EUNICE
Last Name:ADEAGBO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3077
Mailing Address - Country:US
Mailing Address - Phone:773-975-6775
Mailing Address - Fax:
Practice Address - Street 1:850 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3077
Practice Address - Country:US
Practice Address - Phone:773-975-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019375363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209019375OtherMEDICAL LICENSE