Provider Demographics
NPI:1326659210
Name:OLUWA-OKOUGBO, MONSURAT (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MONSURAT
Middle Name:
Last Name:OLUWA-OKOUGBO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MN
Mailing Address - Zip Code:55055-1650
Mailing Address - Country:US
Mailing Address - Phone:651-271-5214
Mailing Address - Fax:
Practice Address - Street 1:1565 11TH AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:MN
Practice Address - Zip Code:55055-1650
Practice Address - Country:US
Practice Address - Phone:651-271-5214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7642363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health