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General NPI Number Information
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NPI Number | 1881174654
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Entity Type | Individual
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Provider Name | FAUSAT FUNMILOLA ODUBIYI NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 08/21/2018
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Last Update Date | 09/23/2024
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Provider Practice Location Address
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Address Line | 1221 N CHURCH ST STE 103-E
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City | MOORESTOWN
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State | NJ
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Zip | 08057-1245
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Country | US
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Telephone | 609-471-3560
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Fax | 833-520-1488
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Provider Business Mailing Address
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Address Line | 1221 N CHURCH ST STE 103-E
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City | MOORESTOWN
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State | NJ
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Zip | 08057-1245
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Country | US
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Telephone | 609-471-3560
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Fax | 833-520-1488
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 26NR22474600
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 402510
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License Number State | NY
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