Provider Demographics
NPI:1730728973
Name:PHANTHALATH, SERINA A
Entity type:Individual
Prefix:
First Name:SERINA
Middle Name:A
Last Name:PHANTHALATH
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 1:2350 S JONES BLVD STE D6
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3103
Mailing Address - Country:US
Mailing Address - Phone:702-510-9982
Mailing Address - Fax:
Practice Address - Street 1:720 MARION DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5414
Practice Address - Country:US
Practice Address - Phone:619-755-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant