Provider Demographics
NPI:1083247621
Name:SOUTHAM, KYAUNA SIU-SHU (MAT, ATC)
Entity Type:Individual
Prefix:
First Name:KYAUNA
Middle Name:SIU-SHU
Last Name:SOUTHAM
Suffix:
Gender:F
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13110 NE 177TH PL # 433
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-5740
Mailing Address - Country:US
Mailing Address - Phone:425-241-7281
Mailing Address - Fax:
Practice Address - Street 1:3351 INLAND EMPIRE BLVD APT 17G
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4863
Practice Address - Country:US
Practice Address - Phone:425-241-7281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program