Provider Demographics
NPI:1487074282
Name:SHOODEH, ZAMZAM
Entity type:Individual
Prefix:
First Name:ZAMZAM
Middle Name:
Last Name:SHOODEH
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 1:207 E LAKE ST
Mailing Address - Street 2:201
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2473
Mailing Address - Country:US
Mailing Address - Phone:612-216-1511
Mailing Address - Fax:612-465-6621
Practice Address - Street 1:207 E LAKE ST
Practice Address - Street 2:201
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2473
Practice Address - Country:US
Practice Address - Phone:612-216-1511
Practice Address - Fax:612-465-6621
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN450797000024251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health