Healthcare Provider Details

I. General information

NPI: 1861192353
Provider Name (Legal Business Name): FATIMA SUFI SYSTEM ADMINISTRATOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 HAZELTINE BLVD STE 484
CHASKA MN
55318-1065
US

IV. Provider business mailing address

1107 HAZELTINE BLVD STE 484
CHASKA MN
55318-1065
US

V. Phone/Fax

Practice location:
  • Phone: 612-446-5480
  • Fax:
Mailing address:
  • Phone: 612-446-5480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number411159
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number411159
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number411159
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number411159
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number411159
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number411159
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number411159
License Number StateMN
# 8
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number411159
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: