Healthcare Provider Details

I. General information

NPI: 1659098416
Provider Name (Legal Business Name): ABISOYE M. OTUNUGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 BAYARD PL
NEWARK NJ
07106-3634
US

IV. Provider business mailing address

240 CENTRAL AVE
EAST ORANGE NJ
07018-3313
US

V. Phone/Fax

Practice location:
  • Phone: 201-349-6816
  • Fax:
Mailing address:
  • Phone: 201-349-6816
  • Fax: 973-414-6730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01349400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: