Healthcare Provider Details

I. General information

NPI: 1437030871
Provider Name (Legal Business Name): RAHMA IDRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9420 4TH ST N
LAKE ELMO MN
55042-4537
US

IV. Provider business mailing address

9420 4TH ST N
LAKE ELMO MN
55042-4537
US

V. Phone/Fax

Practice location:
  • Phone: 612-703-9022
  • Fax:
Mailing address:
  • Phone: 612-703-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: