Healthcare Provider Details

I. General information

NPI: 1154143428
Provider Name (Legal Business Name): LENA A IDRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7524 W 101ST ST
BLOOMINGTON MN
55438-2109
US

IV. Provider business mailing address

7524 W 101ST ST
BLOOMINGTON MN
55438-2109
US

V. Phone/Fax

Practice location:
  • Phone: 612-703-9474
  • Fax:
Mailing address:
  • Phone: 612-703-9474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279P3900X
TaxonomyNeonatal/Pediatric Registered Respiratory Therapist
License Number4205
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: