Healthcare Provider Details

I. General information

NPI: 1144147455
Provider Name (Legal Business Name): OMOTAYO OMOLARA IDOWU FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11476 AUSTIN ST
OSCEOLA IN
46561-9700
US

IV. Provider business mailing address

814 N 3RD ST
GOSHEN IN
46528-7100
US

V. Phone/Fax

Practice location:
  • Phone: 574-318-5517
  • Fax:
Mailing address:
  • Phone: 574-500-3737
  • Fax: 574-534-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28276040
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: