Healthcare Provider Details

I. General information

NPI: 1205444775
Provider Name (Legal Business Name): ANU A OWOFADEJU NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ANU A ADE OWOFADEJU NP

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 S MERIDIAN ST STE 225
INDIANAPOLIS IN
46217-6064
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-865-6922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71010185A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28207520A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: