Provider Demographics
NPI:1740751833
Name:FOLLY-NOTSRON, KANGNI SERGE
Entity Type:Individual
Prefix:
First Name:KANGNI
Middle Name:SERGE
Last Name:FOLLY-NOTSRON
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 1:7920 MOCCASIN TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-8611
Mailing Address - Country:US
Mailing Address - Phone:402-321-6965
Mailing Address - Fax:
Practice Address - Street 1:7920 MOCCASIN TRAIL DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-8611
Practice Address - Country:US
Practice Address - Phone:402-321-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities