Healthcare Provider Details

I. General information

NPI: 1326847807
Provider Name (Legal Business Name): ANTHONY A OKONMAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N BEVERWYCK RD
LAKE HIAWATHA NJ
07034-2624
US

IV. Provider business mailing address

50 N BEVERWYCK RD
LAKE HIAWATHA NJ
07034-2624
US

V. Phone/Fax

Practice location:
  • Phone: 862-872-8981
  • Fax:
Mailing address:
  • Phone: 862-872-8981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0451239712
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: