Provider Demographics
NPI:1902584261
Name:OMORUYI, JOSEPHINE (PMHNP)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:OMORUYI
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7165 GOVERNORS ROW
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9313
Mailing Address - Country:US
Mailing Address - Phone:857-249-0219
Mailing Address - Fax:
Practice Address - Street 1:5602 CAITO DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-1346
Practice Address - Country:US
Practice Address - Phone:317-544-4340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28246477A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health