Provider Demographics
NPI:1255055356
Name:SONUBIISHAQ, DACCU BAMIDELE
Entity type:Individual
Prefix:
First Name:DACCU
Middle Name:BAMIDELE
Last Name:SONUBIISHAQ
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 1:99 LENOX AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-3102
Mailing Address - Country:US
Mailing Address - Phone:309-966-5184
Mailing Address - Fax:
Practice Address - Street 1:99 LENOX AVE FL 1
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-3102
Practice Address - Country:US
Practice Address - Phone:309-966-5184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY953594-01163W00000X
TN97121164W00000X
320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse