=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043125289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHMARK PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2026
-----------------------------------------------------
Last Update Date | 08/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12860 STUTZ CT
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55449-7497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-374-8661
-----------------------------------------------------
Fax | 763-402-7807
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12860 STUTZ CT
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55449-7497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-374-8661
-----------------------------------------------------
Fax | 763-402-7807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TITILOPE OLAOLUWA OMISAKIN
-----------------------------------------------------
Credential | DNP,APRN,PMHNP-BC
-----------------------------------------------------
Telephone | 908-374-8661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------