Provider Demographics
NPI:1942018122
Name:KGOMO, SEIPATI VALERIE
Entity type:Individual
Prefix:
First Name:SEIPATI
Middle Name:VALERIE
Last Name:KGOMO
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 1:178 MEADOW LN APT 203
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2455
Mailing Address - Country:US
Mailing Address - Phone:218-234-5238
Mailing Address - Fax:
Practice Address - Street 1:364 SUNSET AVE
Practice Address - Street 2:306
Practice Address - City:LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:60506
Practice Address - Country:US
Practice Address - Phone:218-234-5238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3747P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty