Provider Demographics
NPI:1033425996
Name:FAHNBULLEH, GADEEH (HOME MAKER)
Entity Type:Individual
Prefix:
First Name:GADEEH
Middle Name:
Last Name:FAHNBULLEH
Suffix:
Gender:F
Credentials:HOME MAKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5775 WAYZATA BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1222
Mailing Address - Country:US
Mailing Address - Phone:651-235-2042
Mailing Address - Fax:
Practice Address - Street 1:7900 ZANE AVE N
Practice Address - Street 2:#104
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-2176
Practice Address - Country:US
Practice Address - Phone:651-235-2042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-28
Last Update Date:2010-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN348032OtherCLASS A PROFRESSIONAL HOME HEALTH CARE AGENCY