Healthcare Provider Details

I. General information

NPI: 1275061525
Provider Name (Legal Business Name): ENIOLA BAMIDELE FNP-BC, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 THOMAS S BOYLAND ST APT 16O
BROOKLYN NY
11233-4149
US

IV. Provider business mailing address

28 VETERANS DR
SOUTH RIVER NJ
08882-2613
US

V. Phone/Fax

Practice location:
  • Phone: 347-661-6980
  • Fax:
Mailing address:
  • Phone: 347-661-6980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR20446300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number677
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01047100
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF345560-01
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01047100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: