Provider Demographics
NPI:1013301407
Name:FOFANA, OLITHA JAMESETTA (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:OLITHA
Middle Name:JAMESETTA
Last Name:FOFANA
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:OLITHA
Other - Middle Name:JAMESETTA
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10911 RHODE ISLAND CIR N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3256
Mailing Address - Country:US
Mailing Address - Phone:763-493-2947
Mailing Address - Fax:
Practice Address - Street 1:10911 RHODE ISLAND CIR N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3256
Practice Address - Country:US
Practice Address - Phone:763-493-2947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 3783363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care