Provider Demographics
NPI:1962898676
Name:OMOMO, ABAYOMI (RN)
Entity type:Individual
Prefix:
First Name:ABAYOMI
Middle Name:
Last Name:OMOMO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 N CONVENT 700-193
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:312-437-1632
Mailing Address - Fax:708-248-7084
Practice Address - Street 1:1511 N CONVENT ST # 700-193
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1470
Practice Address - Country:US
Practice Address - Phone:312-437-1632
Practice Address - Fax:708-248-7084
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.415911163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse