Provider Demographics
NPI:1346615309
Name:KHEM, CHAMNANETH (RN, PHN)
Entity Type:Individual
Prefix:
First Name:CHAMNANETH
Middle Name:
Last Name:KHEM
Suffix:
Gender:M
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-1765
Mailing Address - Country:US
Mailing Address - Phone:562-570-4247
Mailing Address - Fax:562-570-4099
Practice Address - Street 1:2525 GRAND AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1765
Practice Address - Country:US
Practice Address - Phone:562-570-4247
Practice Address - Fax:562-570-4099
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95039171163W00000X
CA548450163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse