Provider Demographics
NPI:1861128282
Name:KANAM, MODELYNE ESSIEN
Entity type:Individual
Prefix:MRS
First Name:MODELYNE
Middle Name:ESSIEN
Last Name:KANAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 GALITZ ST APT 102
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2740
Mailing Address - Country:US
Mailing Address - Phone:847-877-3252
Mailing Address - Fax:
Practice Address - Street 1:1000 SUNSET RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-4008
Practice Address - Country:US
Practice Address - Phone:224-235-4639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005816224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant