Provider Demographics
NPI:1356036529
Name:LIFE SPAN WELLNESS LLC
Entity type:Organization
Organization Name:LIFE SPAN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, PSYCH
Authorized Official - Prefix:
Authorized Official - First Name:ABIODUN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLATUBOSUN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:551-275-5674
Mailing Address - Street 1:156 BALDWIN PL
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-6036
Mailing Address - Country:US
Mailing Address - Phone:551-275-5674
Mailing Address - Fax:
Practice Address - Street 1:156 BALDWIN PL
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-6036
Practice Address - Country:US
Practice Address - Phone:551-275-5674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty