Provider Demographics
NPI:1770038788
Name:OMOLOYIN, ISAAC O (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:O
Last Name:OMOLOYIN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HAMBURG TPKE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2154
Mailing Address - Country:US
Mailing Address - Phone:973-790-9222
Mailing Address - Fax:973-790-0671
Practice Address - Street 1:401 HAMBURG TPKE
Practice Address - Street 2:SUITE 302
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2154
Practice Address - Country:US
Practice Address - Phone:973-790-9222
Practice Address - Fax:973-790-0671
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00661000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health