Provider Demographics
NPI:1225673411
Name:AGENE, OSETOHAMEN ELIZABETH (CNP)
Entity Type:Individual
Prefix:
First Name:OSETOHAMEN
Middle Name:ELIZABETH
Last Name:AGENE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 SHINGLE CREEK PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2485
Mailing Address - Country:US
Mailing Address - Phone:763-647-9868
Mailing Address - Fax:
Practice Address - Street 1:5701 SHINGLE CREEK PKWY STE 115
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-2485
Practice Address - Country:US
Practice Address - Phone:763-208-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20200450452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry