Healthcare Provider Details

I. General information

NPI: 1033425996
Provider Name (Legal Business Name): GADEEH FAHNBULLEH HOME MAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2010
Last Update Date: 08/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 ZANE AVE N #104
BROOKLYN PARK MN
55443-2176
US

IV. Provider business mailing address

5775 WAYZATA BLVD SUITE 700
ST LOUIS PARK MN
55416-1222
US

V. Phone/Fax

Practice location:
  • Phone: 651-235-2042
  • Fax:
Mailing address:
  • Phone: 651-235-2042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: