Healthcare Provider Details

I. General information

NPI: 1275256992
Provider Name (Legal Business Name): OMOKOREDE FATILE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 REISTERSTOWN RD STE 304
PIKESVILLE MD
21208-4336
US

IV. Provider business mailing address

1515 REISTERSTOWN RD STE 304
PIKESVILLE MD
21208-4336
US

V. Phone/Fax

Practice location:
  • Phone: 718-749-4346
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR214086
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR214086
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number125356
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024195935
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71017850A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405486
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: