Healthcare Provider Details

I. General information

NPI: 1871485359
Provider Name (Legal Business Name): DAVID OLATUNBOSUN FOWOPE PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ENIOLA-DAVID OLATUNBOSUN FOWOPE D. FOWOPE PMHNP-BC

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9165 OTIS AVE STE 164
INDIANAPOLIS IN
46216-2312
US

IV. Provider business mailing address

7304 COMBINE DR
LAFAYETTE IN
47905-9542
US

V. Phone/Fax

Practice location:
  • Phone: 765-209-8193
  • Fax:
Mailing address:
  • Phone: 765-209-8193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71016847A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: