Healthcare Provider Details

I. General information

NPI: 1629644539
Provider Name (Legal Business Name): EMMANUEL OWUSU PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 EUCLID ST
WOODBURY NJ
08096-4626
US

IV. Provider business mailing address

1 CONIFER WAY
SICKLERVILLE NJ
08081-4637
US

V. Phone/Fax

Practice location:
  • Phone: 856-885-6804
  • Fax:
Mailing address:
  • Phone: 856-885-6804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01141200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: