Provider Demographics
NPI:1619747219
Name:OGUNSANWO, BOLATITO OLUBUKOLA (APRN, CNP)
Entity type:Individual
Prefix:
First Name:BOLATITO
Middle Name:OLUBUKOLA
Last Name:OGUNSANWO
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 DOTY RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7530
Mailing Address - Country:US
Mailing Address - Phone:815-334-5018
Mailing Address - Fax:815-206-2822
Practice Address - Street 1:3707 DOTY RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7530
Practice Address - Country:US
Practice Address - Phone:815-334-5018
Practice Address - Fax:815-206-2822
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.028763363LP0808X
IL209028763363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health