Provider Demographics
NPI:1841768363
Name:PHANTHADETH-AGUINALDO, SUPHAPHON WENDY (RN)
Entity Type:Individual
Prefix:
First Name:SUPHAPHON
Middle Name:WENDY
Last Name:PHANTHADETH-AGUINALDO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15827 SE BASALT CT
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-8299
Mailing Address - Country:US
Mailing Address - Phone:503-380-5811
Mailing Address - Fax:
Practice Address - Street 1:5329 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3237
Practice Address - Country:US
Practice Address - Phone:503-988-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201807517RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse