Provider Demographics
NPI:1295599892
Name:SEUN, PHALLA KATRINA
Entity type:Individual
Prefix:
First Name:PHALLA
Middle Name:KATRINA
Last Name:SEUN
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 1:1136 22ND ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2995
Mailing Address - Country:US
Mailing Address - Phone:701-200-0964
Mailing Address - Fax:
Practice Address - Street 1:1136 22ND ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2995
Practice Address - Country:US
Practice Address - Phone:701-200-0964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant