Provider Demographics
NPI:1700326600
Name:PHRATHANY, SOUTHONE SUE
Entity Type:Individual
Prefix:
First Name:SOUTHONE
Middle Name:SUE
Last Name:PHRATHANY
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 1:2616 SE 18TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50320-1205
Mailing Address - Country:US
Mailing Address - Phone:515-868-7405
Mailing Address - Fax:
Practice Address - Street 1:2616 SE 18TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1205
Practice Address - Country:US
Practice Address - Phone:515-868-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide