Provider Demographics
NPI:1609540319
Name:SYBANGONE, THENETHONG (CNA)
Entity Type:Individual
Prefix:
First Name:THENETHONG
Middle Name:
Last Name:SYBANGONE
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 WORTH AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3660
Mailing Address - Country:US
Mailing Address - Phone:727-482-6866
Mailing Address - Fax:
Practice Address - Street 1:2420 WORTH AVE
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-3660
Practice Address - Country:US
Practice Address - Phone:727-482-6866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No372600000XNursing Service Related ProvidersAdult Companion