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General NPI Number Information
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NPI Number | 1255055356
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Entity Type | Individual
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Provider Name | DACCU BAMIDELE SONUBIISHAQ
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Gender | Female
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Dates
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Enumeration Date | 10/03/2022
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Last Update Date | 08/13/2025
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Provider Practice Location Address
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Address Line | 99 LENOX AVE FL 1
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City | EAST ORANGE
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State | NJ
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Zip | 07018-3102
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Country | US
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Telephone | 309-966-5184
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Fax |
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Provider Business Mailing Address
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Address Line | 99 LENOX AVE FL 1
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City | EAST ORANGE
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State | NJ
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Zip | 07018-3102
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Country | US
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Telephone | 309-966-5184
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 97121
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 953594-01
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License Number State | NY
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