Individual
SAMSON AJIBOLA OMOWUMI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
5401 N KNOXVILLE AVE, PEORIA, IL 61614-5098
(614) 816-7589
Mailing address
10830 N SAWMILL LN, DUNLAP, IL 61525-7514
(614) 816-7589
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
209.030167
IL
Other
Enumeration date
08/02/2024
Last updated
08/02/2024
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