Healthcare Provider Details

I. General information

NPI: 1801594072
Provider Name (Legal Business Name): OLUSADE O FAKOLADE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 PARK EAST BLVD
LAFAYETTE IN
47905-0785
US

IV. Provider business mailing address

5477 RALFE RD
INDIANAPOLIS IN
46234-3753
US

V. Phone/Fax

Practice location:
  • Phone: 765-743-4400
  • Fax:
Mailing address:
  • Phone: 317-457-7329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71013601A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number71013601A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: