Healthcare Provider Details

I. General information

NPI: 1881452167
Provider Name (Legal Business Name): YETUNDE BOSEDE SOWUNMI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N HIGH SCHOOL RD STE B
INDIANAPOLIS IN
46214-3695
US

IV. Provider business mailing address

10293 KINGS GAP WAY
INDIANAPOLIS IN
46234-9832
US

V. Phone/Fax

Practice location:
  • Phone: 317-291-1211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71015015A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: