Provider Demographics
NPI:1831864099
Name:DWOMOH, GAELLE THIAM (APRN)
Entity type:Individual
Prefix:
First Name:GAELLE
Middle Name:THIAM
Last Name:DWOMOH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:GAELLE
Other - Middle Name:THIAM
Other - Last Name:HOUMGNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 N MARION ST STE 203
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1023
Mailing Address - Country:US
Mailing Address - Phone:312-714-3133
Mailing Address - Fax:312-910-8971
Practice Address - Street 1:101 N MARION ST STE 203
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1023
Practice Address - Country:US
Practice Address - Phone:312-713-3133
Practice Address - Fax:312-910-8971
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.003229363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily