Provider Demographics
NPI:1598389199
Name:ALI, FADUMO AHMED
Entity Type:Individual
Prefix:
First Name:FADUMO
Middle Name:AHMED
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 1:963 S. ROBERT ST. WEST
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1446
Mailing Address - Country:US
Mailing Address - Phone:507-319-1195
Mailing Address - Fax:
Practice Address - Street 1:963 S. ROBERT ST. WEST
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-1446
Practice Address - Country:US
Practice Address - Phone:507-319-1198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-31
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2460612163W00000X
MN9664363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty