Provider Demographics
NPI:1720528342
Name:OGUNLEYE, ADETUTU MOJISOLA SANDRA (CRNM)
Entity Type:Individual
Prefix:MS
First Name:ADETUTU MOJISOLA
Middle Name:SANDRA
Last Name:OGUNLEYE
Suffix:
Gender:F
Credentials:CRNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519-525 WEST STREET
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103
Mailing Address - Country:US
Mailing Address - Phone:856-968-2320
Mailing Address - Fax:856-968-2317
Practice Address - Street 1:519-525 WEST STREET
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103
Practice Address - Country:US
Practice Address - Phone:856-968-2320
Practice Address - Fax:856-968-2317
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC004881367A00000X
NJ26NJ00710400363LA2200X, 363LG0600X
PASP017231363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
NJ0696532Medicaid