Healthcare Provider Details

I. General information

NPI: 1275218083
Provider Name (Legal Business Name): TAKEYAH ROSENTHALL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 W WASHINGTON CENTER RD
FORT WAYNE IN
46825-4142
US

IV. Provider business mailing address

2621 E JEFFERSON ST
WARSAW IN
46580-3880
US

V. Phone/Fax

Practice location:
  • Phone: 260-443-7481
  • Fax: 260-443-7484
Mailing address:
  • Phone: 574-267-7169
  • Fax: 574-269-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71014019A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71014019A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: