Healthcare Provider Details

I. General information

NPI: 1962740191
Provider Name (Legal Business Name): YETUNDE OGUNTADE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 BROADWAY
BROOKLYN NY
11206-5318
US

IV. Provider business mailing address

815 BROADWAY
BROOKLYN NY
11206-5318
US

V. Phone/Fax

Practice location:
  • Phone: 646-614-8329
  • Fax:
Mailing address:
  • Phone: 844-692-4692
  • Fax: 646-614-8385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number346538
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number665819
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: