Provider Demographics
NPI:1881174654
Name:ODUBIYI, FAUSAT FUNMILOLA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:DR
First Name:FAUSAT
Middle Name:FUNMILOLA
Last Name:ODUBIYI
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:DR
Other - First Name:FAUSAT
Other - Middle Name:FUNMILOLA
Other - Last Name:FATOKUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1221 N CHURCH ST STE 103-E
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-1245
Mailing Address - Country:US
Mailing Address - Phone:609-471-3560
Mailing Address - Fax:833-520-1488
Practice Address - Street 1:1221 N CHURCH ST STE 103-E
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-1245
Practice Address - Country:US
Practice Address - Phone:609-471-3560
Practice Address - Fax:833-520-1488
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR22474600363LP0808X
NY402510363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health