Provider Demographics
NPI:1609172444
Name:SRISUTHIPORNSAKUL, CHARISAO (FNP)
Entity Type:Individual
Prefix:
First Name:CHARISAO
Middle Name:
Last Name:SRISUTHIPORNSAKUL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 CAMY ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-7868
Mailing Address - Country:US
Mailing Address - Phone:608-772-6123
Mailing Address - Fax:
Practice Address - Street 1:7201 W GRANDRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6709
Practice Address - Country:US
Practice Address - Phone:509-221-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5098-33363LF0000X
IL209008323363LF0000X
WAAP60435520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily