Provider Demographics
NPI:1477981496
Name:FADIPE, BOLA (DNP)
Entity Type:Individual
Prefix:
First Name:BOLA
Middle Name:
Last Name:FADIPE
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BRAGAW AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-1549
Mailing Address - Country:US
Mailing Address - Phone:862-217-4480
Mailing Address - Fax:
Practice Address - Street 1:2386 MORRIS AVE STE 107-109
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5723
Practice Address - Country:US
Practice Address - Phone:862-217-4480
Practice Address - Fax:862-205-2480
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338222363LF0000X
NJ26NJ00468500363LP0808X, 363LF0000X
NYF404491363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health