Provider Demographics
NPI:1942707567
Name:MOHAMED, FAADUMO OMAR (RN)
Entity Type:Individual
Prefix:
First Name:FAADUMO
Middle Name:OMAR
Last Name:MOHAMED
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1620
Mailing Address - Country:US
Mailing Address - Phone:612-822-1203
Mailing Address - Fax:612-871-2161
Practice Address - Street 1:1229 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1620
Practice Address - Country:US
Practice Address - Phone:612-822-1203
Practice Address - Fax:612-871-2161
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2168607163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN311700000XMedicaid