Healthcare Provider Details

I. General information

NPI: 1861301848
Provider Name (Legal Business Name): OMOTAYO OLANREWAJU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BERGEN ST
NEWARK NJ
07103-2496
US

IV. Provider business mailing address

730 GARDEN ST
UNION NJ
07083-6642
US

V. Phone/Fax

Practice location:
  • Phone: 908-906-3387
  • Fax:
Mailing address:
  • Phone: 908-906-3387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2026002489
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: