Provider Demographics
NPI:1154143428
Name:IDRIS, LENA A
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:A
Last Name:IDRIS
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 1:7524 W 101ST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2109
Mailing Address - Country:US
Mailing Address - Phone:612-703-9474
Mailing Address - Fax:
Practice Address - Street 1:7524 W 101ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-2109
Practice Address - Country:US
Practice Address - Phone:612-703-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42052279P3900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredNeonatal/Pediatrics