Healthcare Provider Details

I. General information

NPI: 1780411587
Provider Name (Legal Business Name): HADIATOU DIALLO'S PRIMARY & MENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 NEWKIRK ST APT 228-229
JERSEY CITY NJ
07306-3021
US

IV. Provider business mailing address

155 WILLOWBROOK BLVD STE 110
WAYNE NJ
07470-7033
US

V. Phone/Fax

Practice location:
  • Phone: 201-618-6623
  • Fax:
Mailing address:
  • Phone: 201-618-6623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: IBRAHIMA DIALLO
Title or Position: OWNER
Credential: NP
Phone: 201-618-6623