Basic Information
| Provider Information | |||||||||
| NPI: | 1205136215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OWOSENI | ||||||||
| FirstName: | OLUKEMI | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 192 WAVERLY DR | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183029061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3475511187 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 192 WAVERLY DR | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183029061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3475511187 | ||||||||
| FaxNumber: | 7323245765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 26NJ00719600 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | 26NJ00719600 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | SP023523 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0562521 | 05 | NJ | MEDICAID |