Provider Demographics
NPI:1396247359
Name:MUTIU, OMONIYI FATAI (APRN)
Entity type:Individual
Prefix:
First Name:OMONIYI
Middle Name:FATAI
Last Name:MUTIU
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E OAKLAND PARK BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4400
Mailing Address - Country:US
Mailing Address - Phone:954-561-6222
Mailing Address - Fax:954-990-7650
Practice Address - Street 1:2055 SUGARLOAF CIR STE 575
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-9804
Practice Address - Country:US
Practice Address - Phone:404-999-7971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9326452363LP0808X, 363LF0000X
GARN286020363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024364200Medicaid