Healthcare Provider Details

I. General information

NPI: 1114871886
Provider Name (Legal Business Name): SHILOH WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 BAYARD PL
NEWARK NJ
07106-3634
US

IV. Provider business mailing address

12 BAYARD PL
NEWARK NJ
07106-3634
US

V. Phone/Fax

Practice location:
  • Phone: 201-349-6816
  • Fax: 856-998-1204
Mailing address:
  • Phone: 201-349-6816
  • Fax: 856-998-1204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VIVIEN OGON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 856-398-0428