Provider Demographics
NPI:1194219907
Name:OTEPOLA, MULIKAT MOYOSORE (APN)
Entity Type:Individual
Prefix:
First Name:MULIKAT
Middle Name:MOYOSORE
Last Name:OTEPOLA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHELSEA AVE APT 1-208
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-8109
Mailing Address - Country:US
Mailing Address - Phone:404-441-8142
Mailing Address - Fax:
Practice Address - Street 1:22 COURT ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-1700
Practice Address - Country:US
Practice Address - Phone:732-780-7387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00828400363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health