Healthcare Provider Details

I. General information

NPI: 1043125289
Provider Name (Legal Business Name): NORTHMARK PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12860 STUTZ CT
BLAINE MN
55449-7497
US

IV. Provider business mailing address

12860 STUTZ CT
BLAINE MN
55449-7497
US

V. Phone/Fax

Practice location:
  • Phone: 908-374-8661
  • Fax: 763-402-7807
Mailing address:
  • Phone: 908-374-8661
  • Fax: 763-402-7807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TITILOPE OLAOLUWA OMISAKIN
Title or Position: OWNER
Credential: DNP,APRN,PMHNP-BC
Phone: 908-374-8661