Healthcare Provider Details

I. General information

NPI: 1508464397
Provider Name (Legal Business Name): ABIMBOLA OTUFALE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 04/30/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 748465
ATLANTA GA
30374-8465
US

IV. Provider business mailing address

252B CAMDEN ST
NEWARK NJ
07103-2434
US

V. Phone/Fax

Practice location:
  • Phone: 855-284-7483
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01068500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number346031
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0102715-C-NP
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405429
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1161913
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: