Healthcare Provider Details

I. General information

NPI: 1215630231
Provider Name (Legal Business Name): DESTINY AWAKENING HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 IRVINE TURNER BLVD
NEWARK NJ
07108-2414
US

IV. Provider business mailing address

458 IRVINE TURNER BLVD
NEWARK NJ
07108-2414
US

V. Phone/Fax

Practice location:
  • Phone: 973-704-8769
  • Fax: 862-305-3790
Mailing address:
  • Phone: 862-571-7577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: LINDA EMEFA NYOMI-EZEANUNA
Title or Position: MANAGER
Credential:
Phone: 862-571-7577