Healthcare Provider Details

I. General information

NPI: 1356245633
Provider Name (Legal Business Name): FARTUN MOHAMUD ABDIMALIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8126 GRAVOIS RD
SAINT LOUIS MO
63123-4723
US

IV. Provider business mailing address

8126 GRAVOIS RD
SAINT LOUIS MO
63123-4723
US

V. Phone/Fax

Practice location:
  • Phone: 314-445-8571
  • Fax:
Mailing address:
  • Phone: 314-445-8571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: