Provider Demographics
NPI:1184070591
Name:OYEFESOBI, GRACE OGHENEKARO
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:OGHENEKARO
Last Name:OYEFESOBI
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:GRACE
Other - Middle Name:OGHENEKARO
Other - Last Name:AKOH-ONOJA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9633 HALE AVE S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-3894
Mailing Address - Country:US
Mailing Address - Phone:651-769-0114
Mailing Address - Fax:
Practice Address - Street 1:8468 TAMARACK VILLAGE
Practice Address - Street 2:CVS MINUTE CLINIC
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-278-5633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4351363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1982927943Medicaid