Provider Demographics
NPI:1053054361
Name:SOONTHORNPONG, KHWANTHIDA (RN)
Entity Type:Individual
Prefix:
First Name:KHWANTHIDA
Middle Name:
Last Name:SOONTHORNPONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1587 W LORANE WAY
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-3931
Mailing Address - Country:US
Mailing Address - Phone:714-658-5881
Mailing Address - Fax:
Practice Address - Street 1:550 N FLOWER ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-2361
Practice Address - Country:US
Practice Address - Phone:714-647-4666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95235554163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse