Healthcare Provider Details

I. General information

NPI: 1346169190
Provider Name (Legal Business Name): LEESHAN FAHNBULLEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 36TH AVE S # 58104
FARGO ND
58104-5153
US

IV. Provider business mailing address

2540 36TH AVE S
FARGO ND
58104-5153
US

V. Phone/Fax

Practice location:
  • Phone: 701-491-0896
  • Fax:
Mailing address:
  • Phone: 701-491-0896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number65136
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: