Provider Demographics
NPI:1598130882
Name:PHATHANAK, SOPHEAP (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:SOPHEAP
Middle Name:
Last Name:PHATHANAK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 MARTINS WOODS LN
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-4048
Mailing Address - Country:US
Mailing Address - Phone:615-481-2474
Mailing Address - Fax:
Practice Address - Street 1:3508 MARTINS WOODS LN
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-4048
Practice Address - Country:US
Practice Address - Phone:615-481-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily