Healthcare Provider Details

I. General information

NPI: 1689965592
Provider Name (Legal Business Name): OLUFISAYO A OWOLABI NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 07/23/2022
Certification Date: 07/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 CARNEGIE PL
VAUXHALL NJ
07088-1408
US

IV. Provider business mailing address

123 CARNEGIE PL
VAUXHALL NJ
07088-1408
US

V. Phone/Fax

Practice location:
  • Phone: 862-220-1881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ01337400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: