Provider Demographics
NPI:1033520101
Name:OSUNNUGA, OLUYINKA GRACE (NP)
Entity Type:Individual
Prefix:MRS
First Name:OLUYINKA
Middle Name:GRACE
Last Name:OSUNNUGA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 TRINITY PL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-5006
Mailing Address - Country:US
Mailing Address - Phone:765-674-3321
Mailing Address - Fax:
Practice Address - Street 1:1540 TRINITY PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5006
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28144611A363LA2200X
IN71004923A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201230310Medicaid
IN169380052Medicare PIN
IN565800018Medicare PIN
IN201230310Medicaid
IN236040194Medicare PIN