Healthcare Provider Details

I. General information

NPI: 1447712781
Provider Name (Legal Business Name): OLANREWAJU FAMAKINWA APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 RIVER AVE
LAKEWOOD NJ
08701-5288
US

IV. Provider business mailing address

1101 WARREN ST
ROSELLE NJ
07203-2735
US

V. Phone/Fax

Practice location:
  • Phone: 732-486-7373
  • Fax: 732-282-7300
Mailing address:
  • Phone: 862-368-5399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00888100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ00888100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: