Healthcare Provider Details

I. General information

NPI: 1700440823
Provider Name (Legal Business Name): OLUFUNKE ELIZABETH OWOLABI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 ASPEN CREST LN
INDIANAPOLIS IN
46254-9514
US

IV. Provider business mailing address

1119 KEYSTONE WAY STE 201B
CARMEL IN
46032-3356
US

V. Phone/Fax

Practice location:
  • Phone: 317-666-5050
  • Fax:
Mailing address:
  • Phone: 317-214-2100
  • Fax: 317-214-2101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF04190305
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: