Provider Demographics
NPI:1508212283
Name:KHAMSOUKTHAVONG, SODASAVANH JOY
Entity Type:Individual
Prefix:
First Name:SODASAVANH
Middle Name:JOY
Last Name:KHAMSOUKTHAVONG
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 1:501 N GRAHAM ST STE 220
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-2014
Mailing Address - Country:US
Mailing Address - Phone:503-413-4710
Mailing Address - Fax:503-413-7148
Practice Address - Street 1:501 N GRAHAM ST STE 220
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-2014
Practice Address - Country:US
Practice Address - Phone:503-413-4710
Practice Address - Fax:503-413-7148
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200570006CNS364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist