Healthcare Provider Details

I. General information

NPI: 1053693010
Provider Name (Legal Business Name): IYINOLA JOEL OGUNLEYE RN, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 LILAC DR N STE 190
GOLDEN VALLEY MN
55422-4544
US

IV. Provider business mailing address

3409 NANCY PL
SHOREVIEW MN
55126-8040
US

V. Phone/Fax

Practice location:
  • Phone: 763-267-8701
  • Fax:
Mailing address:
  • Phone: 952-465-5388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 200800-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7130
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: