Provider Demographics
NPI:1851760763
Name:THOMURE, SISAMOUTH SIPASEUTH (LVN)
Entity Type:Individual
Prefix:
First Name:SISAMOUTH
Middle Name:SIPASEUTH
Last Name:THOMURE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BOWE AVE APT 703
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-3834
Mailing Address - Country:US
Mailing Address - Phone:559-740-6019
Mailing Address - Fax:
Practice Address - Street 1:650 S 5TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5636
Practice Address - Country:US
Practice Address - Phone:408-982-5779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA231848164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse