Provider Demographics
NPI:1598446262
Name:KHONGKHANGAM, PITCHAYA PEARL
Entity Type:Individual
Prefix:
First Name:PITCHAYA
Middle Name:PEARL
Last Name:KHONGKHANGAM
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 1:210 SIMPSON PKWY APT 222
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-5003
Mailing Address - Country:US
Mailing Address - Phone:253-391-9994
Mailing Address - Fax:
Practice Address - Street 1:200 PHYSICAL EDUCATION CLASSROOM
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-9900
Practice Address - Country:US
Practice Address - Phone:509-359-2427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program