Healthcare Provider Details

I. General information

NPI: 1700326600
Provider Name (Legal Business Name): SOUTHONE SUE PHRATHANY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 SE 18TH ST
DES MOINES IA
50320-1205
US

IV. Provider business mailing address

2616 SE 18TH ST
DES MOINES IA
50320-1205
US

V. Phone/Fax

Practice location:
  • Phone: 515-868-7405
  • Fax:
Mailing address:
  • Phone: 515-868-7405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: