Healthcare Provider Details

I. General information

NPI: 1568041069
Provider Name (Legal Business Name): TASNIM MUSHANNEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2021
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 BEAM AVE STE 100
MAPLEWOOD MN
55109-1128
US

IV. Provider business mailing address

1747 BEAM AVE STE 100
MAPLEWOOD MN
55109-1128
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-6688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number80435
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: