Healthcare Provider Details

I. General information

NPI: 1083258933
Provider Name (Legal Business Name): JENNEH KOTAY GBEHAN DNP-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 OLSON MEMORIAL HWY
GOLDEN VALLEY MN
55422-5147
US

IV. Provider business mailing address

1007 CREEKWOOD DR N
CHAMPLIN MN
55316-1648
US

V. Phone/Fax

Practice location:
  • Phone: 763-496-5708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6866866
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: