Basic Information
| Provider Information | |||||||||
| NPI: | 1942946207 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLUGA | ||||||||
| FirstName: | OLABODE | ||||||||
| MiddleName: | MOSES | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014361381 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 WESTBROOK CORPORATE CTR STE 300 | ||||||||
| Address2: | |||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479294766 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2022 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 209024960 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.