Provider Demographics
NPI:1174286124
Name:FALLON, STELL AUSTIN
Entity Type:Individual
Prefix:
First Name:STELL
Middle Name:AUSTIN
Last Name:FALLON
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 1:1313 14TH ST SE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-4017
Mailing Address - Country:US
Mailing Address - Phone:701-350-0713
Mailing Address - Fax:
Practice Address - Street 1:1020 WASHINGTON ST SE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-3220
Practice Address - Country:US
Practice Address - Phone:701-350-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant