Provider Demographics
NPI:1770300949
Name:SERENE PSYCHIATRIC SERVICES LLC
Entity type:Organization
Organization Name:SERENE PSYCHIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AKENZUA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGBATOR
Authorized Official - Suffix:
Authorized Official - Credentials:CNP, PMHNP
Authorized Official - Phone:651-216-3339
Mailing Address - Street 1:4253 46TH AVE N APT 305
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 W LAKE ST STE 350
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2952
Practice Address - Country:US
Practice Address - Phone:612-979-2276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-20
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty