Healthcare Provider Details

I. General information

NPI: 1811708100
Provider Name (Legal Business Name): BUKOLA OLUWASHOLA KUTI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BUKOLA OLUWASHOLA AWOSANYA

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 03/05/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4265 CORN SILK LN
WOODBURY MN
55129-2213
US

IV. Provider business mailing address

4265 CORN SILK LN
WOODBURY MN
55129-2213
US

V. Phone/Fax

Practice location:
  • Phone: 651-230-1900
  • Fax:
Mailing address:
  • Phone: 651-230-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1077716
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12493
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: