Provider Demographics
NPI:1629558572
Name:OMISORE, JUMOKE FADEKE (NP)
Entity type:Individual
Prefix:MRS
First Name:JUMOKE
Middle Name:FADEKE
Last Name:OMISORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 WINFIELDS LN
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1127
Mailing Address - Country:US
Mailing Address - Phone:410-790-9640
Mailing Address - Fax:
Practice Address - Street 1:1529 WINFIELDS LN
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1127
Practice Address - Country:US
Practice Address - Phone:410-790-9640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRI47715363LF0000X
MDR147715363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty