Healthcare Provider Details

I. General information

NPI: 1750041216
Provider Name (Legal Business Name): OLUFUNKE PATIENCE MOMOH DNP, FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2021
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 PARKVIEW CIRCLE DR
FORT WAYNE IN
46845-1739
US

IV. Provider business mailing address

12423 STONEBORO CT
FORT WAYNE IN
46845-9570
US

V. Phone/Fax

Practice location:
  • Phone: 833-724-8326
  • Fax: 260-266-7935
Mailing address:
  • Phone: 317-561-0525
  • Fax: 260-327-4551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71012002A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP70104990
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71012002A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC006377
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAC009048
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP70104990
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: