Healthcare Provider Details

I. General information

NPI: 1700201241
Provider Name (Legal Business Name): TAIWO GBADEBO APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 CENTENNIAL BLVD STE 3
VOORHEES NJ
08043-9544
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-751-2300
  • Fax: 856-751-2333
Mailing address:
  • Phone: 856-751-2300
  • Fax: 856-751-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NR13633700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP012781
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: