Healthcare Provider Details

I. General information

NPI: 1457215196
Provider Name (Legal Business Name): JOHNTHAP OBAKPOLOR
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 HAYWARD AVE N
OAKDALE MN
55128-7127
US

IV. Provider business mailing address

12682 88TH AVE N
MAPLE GROVE MN
55369-3044
US

V. Phone/Fax

Practice location:
  • Phone: 651-410-7955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13722
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: