Provider Demographics
NPI:1154967230
Name:FADONOUGBO, RISKAT (PMHNP)
Entity type:Individual
Prefix:
First Name:RISKAT
Middle Name:
Last Name:FADONOUGBO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:RISKAT
Other - Middle Name:
Other - Last Name:JANKALAWI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP
Mailing Address - Street 1:6419 N SACRAMENTO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4214
Mailing Address - Country:US
Mailing Address - Phone:773-671-6853
Mailing Address - Fax:
Practice Address - Street 1:800 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4906
Practice Address - Country:US
Practice Address - Phone:773-702-0660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-23
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041399212363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health