Provider Demographics
NPI:1437872314
Name:ALI, FARDOUS
Entity Type:Individual
Prefix:
First Name:FARDOUS
Middle Name:
Last Name:ALI
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 1:525 METRO PL N STE 100
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-5343
Mailing Address - Country:US
Mailing Address - Phone:855-289-1722
Mailing Address - Fax:
Practice Address - Street 1:525 METRO PL N STE 100
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5343
Practice Address - Country:US
Practice Address - Phone:855-289-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHIR.0975376163WA0400X
OHRN.522565163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid