Provider Demographics
NPI:1407461403
Name:KUNKAEW, NETTHIP
Entity Type:Individual
Prefix:MS
First Name:NETTHIP
Middle Name:
Last Name:KUNKAEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 AVONOAK TER
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-1509
Mailing Address - Country:US
Mailing Address - Phone:818-967-2471
Mailing Address - Fax:
Practice Address - Street 1:920 AVONOAK TER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-1509
Practice Address - Country:US
Practice Address - Phone:818-967-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79832225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist