Provider Demographics
NPI:1346770575
Name:ODUSANYA, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ODUSANYA
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 1:454 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1158
Mailing Address - Country:US
Mailing Address - Phone:908-312-0288
Mailing Address - Fax:908-484-9447
Practice Address - Street 1:454 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1158
Practice Address - Country:US
Practice Address - Phone:908-312-0288
Practice Address - Fax:908-484-9447
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00735000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily