Provider Demographics
NPI:1154293777
Name:AKINGBOLA, OMOLARA O (RDN)
Entity type:Individual
Prefix:
First Name:OMOLARA
Middle Name:O
Last Name:AKINGBOLA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 W CHASE AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2423
Mailing Address - Country:US
Mailing Address - Phone:773-690-3607
Mailing Address - Fax:
Practice Address - Street 1:2060 W CHASE AVE APT 3C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-2423
Practice Address - Country:US
Practice Address - Phone:773-690-3607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-22
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164011839133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered