Provider Demographics
NPI:1316038532
Name:KHAMVONGS, NIT (CRNA)
Entity Type:Individual
Prefix:
First Name:NIT
Middle Name:
Last Name:KHAMVONGS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4511
Mailing Address - Country:US
Mailing Address - Phone:772-299-1404
Mailing Address - Fax:772-299-1455
Practice Address - Street 1:3500 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4511
Practice Address - Country:US
Practice Address - Phone:772-299-1404
Practice Address - Fax:772-299-1455
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9232218367500000X
FL9232218363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307376900Medicaid