Healthcare Provider Details

I. General information

NPI: 1194109744
Provider Name (Legal Business Name): HENRY ADEWOLE IBITOKUN APN-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MIDDLESEX TPKE STE 210
ISELIN NJ
08830-2033
US

IV. Provider business mailing address

200 MIDDLESEX ESSEX TPKE STE 210
ISELIN NJ
08830-2033
US

V. Phone/Fax

Practice location:
  • Phone: 315-610-6702
  • Fax: 315-610-6703
Mailing address:
  • Phone: 315-610-6702
  • Fax: 315-610-6703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number307386
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00578600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF348698-01
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00578600
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11683
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ00578600
License Number StateNJ
# 7
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number307386
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number404894
License Number StateNY
# 9
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00578600
License Number StateNJ
# 10
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61303774
License Number StateWA
# 11
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11683
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: