Provider Demographics
NPI:1639617830
Name:FAWIBE, ENIOLA OLUWATOSIN (NP-C)
Entity Type:Individual
Prefix:
First Name:ENIOLA
Middle Name:OLUWATOSIN
Last Name:FAWIBE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ENIOLA
Other - Middle Name:OLUWATOSIN
Other - Last Name:FABUNMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:7333 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6280
Practice Address - Country:US
Practice Address - Phone:260-458-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006932A363LF0000X, 363L00000X
IN28232019A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse