MEDICARE: ADESUWA ELIZABETH OMORAGBON RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F407403-01	NY

General Provider Information

NPI Number	:	1679262745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADESUWA ELIZABETH OMORAGBON RN

Provider Business Mailing Address
First Line	:	68 CLARIDGE AVE
Second Line	:
City	:	ELMONT
State	:	NY
Zip	:	11003-1507
Country	:	US
Telephone Number	:	718-216-7773
Fax Number	:

Provider Business Practice Location Address
First Line	:	68 CLARIDGE AVE
Second Line	:
City	:	ELMONT
State	:	NY
Zip	:	11003-1507
Country	:	US
Telephone Number	:	718-216-7773
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2023
Last Update Date	:	01/16/2026

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