Provider Demographics
NPI:1407678519
Name:MOMODU, LUCY OMONUWA
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:OMONUWA
Last Name:MOMODU
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 1:31 GLASGOW RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-2942
Mailing Address - Country:US
Mailing Address - Phone:856-625-3021
Mailing Address - Fax:
Practice Address - Street 1:31 GLASGOW RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-2942
Practice Address - Country:US
Practice Address - Phone:856-625-3021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15138700363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health