Provider Demographics
NPI:1821767435
Name:SUKRUTTANAVASIN, POONCHIDA
Entity Type:Individual
Prefix:
First Name:POONCHIDA
Middle Name:
Last Name:SUKRUTTANAVASIN
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 1:5975 TERRAPIN PL UNIT 102
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-5459
Mailing Address - Country:US
Mailing Address - Phone:571-365-1579
Mailing Address - Fax:
Practice Address - Street 1:5975 TERRAPIN PL UNIT 102
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-5459
Practice Address - Country:US
Practice Address - Phone:571-365-1579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019014665225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist