Healthcare Provider Details

I. General information

NPI: 1013699693
Provider Name (Legal Business Name): ERONMWON E BALOGUN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1181 NIXON DR. SUITE 1098
MOORESTOWN NJ
08057-3201
US

IV. Provider business mailing address

1181 NIXON DR
MOORESTOWN NJ
08057-3201
US

V. Phone/Fax

Practice location:
  • Phone: 609-444-8109
  • Fax:
Mailing address:
  • Phone: 609-444-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ14894800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number26NR1900140
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: