Provider Demographics
NPI:1366267056
Name:ANIMASHAUN, OMOLOLA WASILAT (PMHNP)
Entity type:Individual
Prefix:
First Name:OMOLOLA
Middle Name:WASILAT
Last Name:ANIMASHAUN
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 1:741 TREELINE DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-4326
Mailing Address - Country:US
Mailing Address - Phone:708-271-2171
Mailing Address - Fax:
Practice Address - Street 1:411 W RIVER RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1570
Practice Address - Country:US
Practice Address - Phone:847-281-5394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209031077363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health