1639717333 NPI number — AMINAT FUNMILAYO ADEDAYO NURSE PRACTITIONER

Table of content: AMINAT FUNMILAYO ADEDAYO NURSE PRACTITIONER (NPI 1639717333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639717333 NPI number — AMINAT FUNMILAYO ADEDAYO NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADEDAYO
Provider First Name:
AMINAT
Provider Middle Name:
FUNMILAYO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639717333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1247 TERRACE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLEWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55109-5511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-235-4042
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
671 VANDALIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-696-5521
Provider Business Practice Location Address Fax Number:
651-696-5544
Provider Enumeration Date:
12/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  6979 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6979 . This is a "MN LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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