Provider Demographics
NPI:1598393993
Name:IBRAHIM, FADUMO
Entity Type:Individual
Prefix:
First Name:FADUMO
Middle Name:
Last Name:IBRAHIM
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 1:3505 8TH ST S STE 4
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5108
Mailing Address - Country:US
Mailing Address - Phone:701-541-5975
Mailing Address - Fax:
Practice Address - Street 1:3505 8TH ST S STE 4
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5108
Practice Address - Country:US
Practice Address - Phone:701-541-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR48749163W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1487283Medicaid