Provider Demographics
NPI:1376703603
Name:TIENSAWANG, THANUTTHA (RN)
Entity Type:Individual
Prefix:MR
First Name:THANUTTHA
Middle Name:
Last Name:TIENSAWANG
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21529 SATICOY ST
Mailing Address - Street 2:UNIT #106
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-4958
Mailing Address - Country:US
Mailing Address - Phone:310-478-3711
Mailing Address - Fax:
Practice Address - Street 1:21529 SATICOY ST
Practice Address - Street 2:UNIT #106
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-4958
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA545790163WE0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0900XNursing Service ProvidersRegistered NurseEnterostomal Therapy