Provider Demographics
NPI:1801594072
Name:FAKOLADE, OLUSADE O
Entity type:Individual
Prefix:
First Name:OLUSADE
Middle Name:O
Last Name:FAKOLADE
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 1:5477 RALFE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-3753
Mailing Address - Country:US
Mailing Address - Phone:317-457-7329
Mailing Address - Fax:
Practice Address - Street 1:833 PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0785
Practice Address - Country:US
Practice Address - Phone:765-743-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013601A363LP0808X, 163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent