Provider Demographics
NPI:1578286688
Name:OMWENGA, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:OMWENGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 GIFFORD CT APT 2
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3001
Mailing Address - Country:US
Mailing Address - Phone:973-980-8727
Mailing Address - Fax:
Practice Address - Street 1:401 HAMBURG TPKE STE 302
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2139
Practice Address - Country:US
Practice Address - Phone:973-790-9222
Practice Address - Fax:973-790-0671
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-22
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01370900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health