Provider Demographics
NPI:1457012783
Name:GHALEY, INDRA MAYA
Entity Type:Individual
Prefix:
First Name:INDRA
Middle Name:MAYA
Last Name:GHALEY
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 1:4231 33RD AVE S APT 303
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6996
Mailing Address - Country:US
Mailing Address - Phone:701-306-9118
Mailing Address - Fax:
Practice Address - Street 1:4231 33RD AVE S APT 303
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6996
Practice Address - Country:US
Practice Address - Phone:701-306-9118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-08
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant