Provider Demographics
NPI:1265079404
Name:SOURIYATHAY, PHINSAYKEO
Entity type:Individual
Prefix:MISS
First Name:PHINSAYKEO
Middle Name:
Last Name:SOURIYATHAY
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 1:6231 SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55428-2732
Mailing Address - Country:US
Mailing Address - Phone:612-368-1236
Mailing Address - Fax:
Practice Address - Street 1:9300 PENN AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-1166
Practice Address - Country:US
Practice Address - Phone:612-368-1236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD1245705Medicaid