Healthcare Provider Details

I. General information

NPI: 1821899584
Provider Name (Legal Business Name): CONRAD OLURANTI OLONIMOYO PMHNP-BC
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 BLOOMINGDALE RD
WHITE PLAINS NY
10605-1504
US

IV. Provider business mailing address

21 BLOOMINGDALE RD
WHITE PLAINS NY
10605-1504
US

V. Phone/Fax

Practice location:
  • Phone: 929-499-4540
  • Fax:
Mailing address:
  • Phone: 929-499-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF406694
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: