Healthcare Provider Details

I. General information

NPI: 1205542297
Provider Name (Legal Business Name): ADEBOWALE OSISANYA PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 FIR ST
EAST CHICAGO IN
46312-3049
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-392-7466
  • Fax: 219-392-7470
Mailing address:
  • Phone: 219-392-7084
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71013569A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: