Provider Demographics
NPI:1679041420
Name:OMORUYI, ABIMBOLA
Entity Type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:
Last Name:OMORUYI
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 1:252 ROUTE 601
Mailing Address - Street 2:
Mailing Address - City:BELLE MEAD
Mailing Address - State:NJ
Mailing Address - Zip Code:08502-3923
Mailing Address - Country:US
Mailing Address - Phone:908-281-1000
Mailing Address - Fax:
Practice Address - Street 1:252 ROUTE 601
Practice Address - Street 2:
Practice Address - City:BELLE MEAD
Practice Address - State:NJ
Practice Address - Zip Code:08502-3923
Practice Address - Country:US
Practice Address - Phone:908-281-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00876700363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1679041420Medicaid