Provider Demographics
NPI:1962710673
Name:OMOAGHE, MAUREEN OTEMURE
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:OTEMURE
Last Name:OMOAGHE
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 1:675 LINCOLN AVE
Mailing Address - Street 2:APT 12B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-4045
Mailing Address - Country:US
Mailing Address - Phone:347-404-6258
Mailing Address - Fax:
Practice Address - Street 1:675 LINCOLN AVE
Practice Address - Street 2:APT 12B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-4045
Practice Address - Country:US
Practice Address - Phone:347-404-6258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY560143163WS0200X
TX1177710363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WS0200XNursing Service ProvidersRegistered NurseSchool