Healthcare Provider Details

I. General information

NPI: 1790657633
Provider Name (Legal Business Name): OLUBODUN AJIBAYO OFAKUNRIN PMHNP, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

IV. Provider business mailing address

1811 WEIR DR STE 270
WOODBURY MN
55125-6741
US

V. Phone/Fax

Practice location:
  • Phone: 651-628-9566
  • Fax: 651-628-0411
Mailing address:
  • Phone: 651-714-9646
  • Fax: 651-714-9647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13390
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: