Provider Demographics
NPI:1154296002
Name:URDOOH, AYANLE
Entity type:Individual
Prefix:
First Name:AYANLE
Middle Name:
Last Name:URDOOH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 MINNEHAHA AVE W APT 106
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1518
Mailing Address - Country:US
Mailing Address - Phone:651-202-7403
Mailing Address - Fax:
Practice Address - Street 1:907 MINNEHAHA AVE W APT 106
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1518
Practice Address - Country:US
Practice Address - Phone:651-202-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNQ387106405118172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver