Healthcare Provider Details

I. General information

NPI: 1104795863
Provider Name (Legal Business Name): JOANN OSASUMWEN IMASUEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4533 NORMANDALE HIGHLANDS DR
BLOOMINGTON MN
55437-2310
US

IV. Provider business mailing address

4533 NORMANDALE HIGHLANDS DR
BLOOMINGTON MN
55437-2310
US

V. Phone/Fax

Practice location:
  • Phone: 612-481-7126
  • Fax:
Mailing address:
  • Phone: 612-481-7126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2486086
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: