MEDICARE: PRO PEACE NP IN PSYCHIATRY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1346012614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO PEACE NP IN PSYCHIATRY PLLC

Provider Business Mailing Address
First Line	:	11 DUNDAR RD STE 207
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	981 BAY ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-4903
Country	:	US
Telephone Number	:	862-297-3732
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OLUBUNMI ADETULE
Credential	:
Telephone Number	:	862-297-3732

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	10/30/2023

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