Provider Demographics
NPI:1538822317
Name:OLUTADE, TEMITOPE (PMHNP)
Entity type:Individual
Prefix:
First Name:TEMITOPE
Middle Name:
Last Name:OLUTADE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S MARION ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2809
Mailing Address - Country:US
Mailing Address - Phone:773-629-1231
Mailing Address - Fax:708-383-7780
Practice Address - Street 1:5359 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1450
Practice Address - Country:US
Practice Address - Phone:773-836-2785
Practice Address - Fax:773-836-7381
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024131363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health