Provider Demographics
NPI:1689976367
Name:PARUCHABUTR, KOMKWUAN PHOLTAVEE (WHNP-BC, FNP-BC, CNM)
Entity Type:Individual
Prefix:MRS
First Name:KOMKWUAN
Middle Name:PHOLTAVEE
Last Name:PARUCHABUTR
Suffix:
Gender:F
Credentials:WHNP-BC, FNP-BC, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 PATRICK ST SW
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-6740
Mailing Address - Country:US
Mailing Address - Phone:703-424-5112
Mailing Address - Fax:
Practice Address - Street 1:9600 DEWITT LOOP
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060
Practice Address - Country:US
Practice Address - Phone:703-424-5112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207275163WW0101X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory