Provider Demographics
NPI:1780198192
Name:AGBOLADE, BAYO BABATUNDE (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:BAYO
Middle Name:BABATUNDE
Last Name:AGBOLADE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4711 MIDLOTHIAN TPKE STE 14
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-4903
Mailing Address - Country:US
Mailing Address - Phone:708-743-2714
Mailing Address - Fax:
Practice Address - Street 1:4711 MIDLOTHIAN TPKE STE 14
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-4903
Practice Address - Country:US
Practice Address - Phone:708-743-2714
Practice Address - Fax:708-251-8848
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
IL209.025433363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3001470OtherIDPH