Provider Demographics
NPI:1508464397
Name:OTUFALE, ABIMBOLA (PMHNP)
Entity type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:
Last Name:OTUFALE
Suffix:
Gender:
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252B CAMDEN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 748465
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30374-8465
Practice Address - Country:US
Practice Address - Phone:855-284-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01068500363LP0808X
NY346031363LF0000X
COC-APN.0102715-C-NP363LP0808X
NY405429363LP0808X
TX1161913363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner