Provider Demographics
NPI:1801540216
Name:LAWAL, ADEREMI
Entity type:Individual
Prefix:
First Name:ADEREMI
Middle Name:
Last Name:LAWAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 VINCENNES AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3458
Mailing Address - Country:US
Mailing Address - Phone:877-692-8686
Mailing Address - Fax:708-754-2051
Practice Address - Street 1:1536 VINCENNES AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3458
Practice Address - Country:US
Practice Address - Phone:877-692-8686
Practice Address - Fax:708-754-2951
Is Sole Proprietor?:No
Enumeration Date:2022-02-05
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL024569363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily