MEDICARE: TAKEYAH ROSENTHALL FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	71014019A	IN
2	363LF0000X	Family Nurse Practitioner	71014019A	IN

General Provider Information

NPI Number	:	1275218083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAKEYAH ROSENTHALL FNP

Provider Business Mailing Address
First Line	:	2621 E JEFFERSON ST
Second Line	:
City	:	WARSAW
State	:	IN
Zip	:	46580-3880
Country	:	US
Telephone Number	:	574-267-7169
Fax Number	:	574-269-4189

Provider Business Practice Location Address
First Line	:	1313 W WASHINGTON CENTER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-4142
Country	:	US
Telephone Number	:	260-443-7481
Fax Number	:	260-443-7484

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2023
Last Update Date	:	12/17/2025

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