Healthcare Provider Details

I. General information

NPI: 1598540700
Provider Name (Legal Business Name): MAYOWA OKUNEYE CNP, MSN, MBBS, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 BUNKER LAKE BLVD NW
ANDOVER MN
55304-7402
US

IV. Provider business mailing address

11310 JOHNSON ST NE
BLAINE MN
55434-2835
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-5011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2477905
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number28761
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9999
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: