Provider Demographics
NPI:1104699263
Name:ARISE, IBITAYO K
Entity type:Individual
Prefix:
First Name:IBITAYO
Middle Name:K
Last Name:ARISE
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 1:8471 BALLYSHANNON DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7320
Mailing Address - Country:US
Mailing Address - Phone:317-985-5899
Mailing Address - Fax:
Practice Address - Street 1:3850 SHORE DR STE 315
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4693
Practice Address - Country:US
Practice Address - Phone:317-429-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014315A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health