Provider Demographics
NPI:1124843792
Name:OMOTAYO, OLUWABUNMI
Entity type:Individual
Prefix:
First Name:OLUWABUNMI
Middle Name:
Last Name:OMOTAYO
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 1:421 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-1228
Mailing Address - Country:US
Mailing Address - Phone:347-302-1212
Mailing Address - Fax:
Practice Address - Street 1:421 RIVER RD
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NJ
Practice Address - Zip Code:07928-1228
Practice Address - Country:US
Practice Address - Phone:347-302-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15144400363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health