Healthcare Provider Details

I. General information

NPI: 1619850534
Provider Name (Legal Business Name): ABIOLA OLAFARE AMUSAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PENDLETON JUVENILE CORRECTIONAL FACILITY
PENDLETON IN
46064
US

IV. Provider business mailing address

PENDLETON JUVENILE CORRECTIONAL FACILITY
PENDLETON IN
46064
US

V. Phone/Fax

Practice location:
  • Phone: 765-778-3778
  • Fax:
Mailing address:
  • Phone: 765-778-3778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71017031A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28280085A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: