Healthcare Provider Details

I. General information

NPI: 1003743444
Provider Name (Legal Business Name): WALEADE OMOWUMI YUSUF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 WESTFIELD AVE
CLARK NJ
07066-1323
US

IV. Provider business mailing address

275 PROSPECT ST APT 11F
EAST ORANGE NJ
07017-2879
US

V. Phone/Fax

Practice location:
  • Phone: 862-930-0305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ15569400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: