Provider Demographics
NPI:1861192353
Name:SUFI, FATIMA (SYSTEM ADMINISTRATOR)
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:
Last Name:SUFI
Suffix:
Gender:F
Credentials:SYSTEM ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 HAZELTINE BLVD STE 484
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1065
Mailing Address - Country:US
Mailing Address - Phone:612-446-5480
Mailing Address - Fax:
Practice Address - Street 1:1107 HAZELTINE BLVD STE 484
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1065
Practice Address - Country:US
Practice Address - Phone:612-446-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4111591041C0700X, 122300000X, 251J00000X, 253J00000X, 261Q00000X, 261QR0800X, 310400000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No122300000XDental ProvidersDentist
No251J00000XAgenciesNursing Care
No253J00000XAgenciesFoster Care Agency
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN411159OtherMINNESOTA DEPARTMENT OF HEALTH