Provider Demographics
NPI:1265241210
Name:ONIFADE, OLUWASEUN MODUPE
Entity type:Individual
Prefix:MRS
First Name:OLUWASEUN
Middle Name:MODUPE
Last Name:ONIFADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13192 GLENSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-8864
Mailing Address - Country:US
Mailing Address - Phone:317-332-9667
Mailing Address - Fax:
Practice Address - Street 1:13192 GLENSIDE DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-8864
Practice Address - Country:US
Practice Address - Phone:317-332-9667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-04
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71016191A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care