Healthcare Provider Details

I. General information

NPI: 1205635141
Provider Name (Legal Business Name): SESAN L OGUNNIRAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 BROOKLYN BLVD STE 100
BROOKLYN CENTER MN
55429-1755
US

IV. Provider business mailing address

18927 100TH PL N
MAPLE GROVE MN
55311-2270
US

V. Phone/Fax

Practice location:
  • Phone: 612-886-9404
  • Fax:
Mailing address:
  • Phone: 612-501-4029
  • Fax: 612-501-4029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2086187
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: