Provider Demographics
NPI:1730773656
Name:OTETUBI, IBIRONKE
Entity type:Individual
Prefix:MRS
First Name:IBIRONKE
Middle Name:
Last Name:OTETUBI
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 1:59 KOCH AVE
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950-4400
Mailing Address - Country:US
Mailing Address - Phone:977-538-1800
Mailing Address - Fax:
Practice Address - Street 1:59 KOCH AVE
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-4400
Practice Address - Country:US
Practice Address - Phone:977-538-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01094000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health