Provider Demographics
NPI:1154844686
Name:DIALLO-YOUNG, BOLO OUMAR (FNP)
Entity Type:Individual
Prefix:
First Name:BOLO
Middle Name:OUMAR
Last Name:DIALLO-YOUNG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BOLO
Other - Middle Name:O
Other - Last Name:DIALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:549 BEAN ST # 1
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2040
Mailing Address - Country:US
Mailing Address - Phone:612-986-6063
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5272363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner