Provider Demographics
NPI:1104621416
Name:OBU, KAMSIYOCHUKWU
Entity type:Individual
Prefix:
First Name:KAMSIYOCHUKWU
Middle Name:
Last Name:OBU
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 BURNT TAVERN RD STE 1A
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-1496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 BURNT TAVERN RD STE 1A
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-1496
Practice Address - Country:US
Practice Address - Phone:908-417-0632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15276900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health