Provider Demographics
NPI:1154011120
Name:IKWU, BOLAKALE (PMHNP-BC,MSN,CNL,RN)
Entity type:Individual
Prefix:
First Name:BOLAKALE
Middle Name:
Last Name:IKWU
Suffix:
Gender:F
Credentials:PMHNP-BC,MSN,CNL,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1572 RIDGEWAY ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5130
Mailing Address - Country:US
Mailing Address - Phone:973-449-9885
Mailing Address - Fax:
Practice Address - Street 1:936 STUYVESANT AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-6991
Practice Address - Country:US
Practice Address - Phone:973-449-9885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01481700363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health