Provider Demographics
NPI:1811639719
Name:OSMAN, FATUMA A (OWNER)
Entity type:Individual
Prefix:
First Name:FATUMA
Middle Name:A
Last Name:OSMAN
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 68TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4717
Mailing Address - Country:US
Mailing Address - Phone:651-500-9304
Mailing Address - Fax:
Practice Address - Street 1:1600 68TH AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4717
Practice Address - Country:US
Practice Address - Phone:651-500-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA777918200Medicaid