Provider Demographics
NPI:1275061525
Name:BAMIDELE, ENIOLA (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ENIOLA
Middle Name:
Last Name:BAMIDELE
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08882-2613
Mailing Address - Country:US
Mailing Address - Phone:347-661-6980
Mailing Address - Fax:
Practice Address - Street 1:249 THOMAS S BOYLAND ST APT 16O
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-4149
Practice Address - Country:US
Practice Address - Phone:347-661-6980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR20446300163W00000X
NY677163W00000X
NJ26NJ01047100363LF0000X, 363LP0808X
NYF345560-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily