Provider Demographics
NPI:1407219645
Name:ISSE, FOWSIA S
Entity Type:Individual
Prefix:
First Name:FOWSIA
Middle Name:S
Last Name:ISSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 JOLLY LN NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-5049
Mailing Address - Country:US
Mailing Address - Phone:612-978-7470
Mailing Address - Fax:
Practice Address - Street 1:5519 LYNDALE AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-3216
Practice Address - Country:US
Practice Address - Phone:612-978-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPENDINGOtherADULT FOSTER CARE