Healthcare Provider Details

I. General information

NPI: 1013301407
Provider Name (Legal Business Name): OLITHA JAMESETTA FOFANA AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLITHA JAMESETTA COLLINS

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10911 RHODE ISLAND CIR N
CHAMPLIN MN
55316-3256
US

IV. Provider business mailing address

10911 RHODE ISLAND CIR N
CHAMPLIN MN
55316-3256
US

V. Phone/Fax

Practice location:
  • Phone: 763-493-2947
  • Fax:
Mailing address:
  • Phone: 763-493-2947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP 3783
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP 3783
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCNP 3783
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: