Healthcare Provider Details

I. General information

NPI: 1760672554
Provider Name (Legal Business Name): FATIMAH ADEBUKOLA OLORIEGBE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FATIMAH AYINLA

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 2ND ST SE
LITTLE FALLS MN
56345-3559
US

IV. Provider business mailing address

811 2ND ST SE STE A
LITTLE FALLS MN
56345-3558
US

V. Phone/Fax

Practice location:
  • Phone: 320-631-7200
  • Fax: 206-320-5343
Mailing address:
  • Phone: 320-631-7200
  • Fax: 206-320-5343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036124213
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125-053767
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67108
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: