Provider Demographics
NPI:1609388222
Name:ADESANLU, OLUFUNMILAYO ABIMBOLA
Entity type:Individual
Prefix:
First Name:OLUFUNMILAYO
Middle Name:ABIMBOLA
Last Name:ADESANLU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RECTOR AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-3325
Mailing Address - Country:US
Mailing Address - Phone:848-309-5141
Mailing Address - Fax:
Practice Address - Street 1:367 BERRY ST STE 104
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-3341
Practice Address - Country:US
Practice Address - Phone:848-309-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-05
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000108363LP0808X
NY402321363LP0808X
NJ26NJ00775300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health