Provider Demographics
NPI:1932074630
Name:RATTANAPHONG, WATCHARIDA
Entity type:Individual
Prefix:
First Name:WATCHARIDA
Middle Name:
Last Name:RATTANAPHONG
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 1:1 ELY PARK BLVD
Mailing Address - Street 2:9-4
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 ELY PARK BLVD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1480
Practice Address - Country:US
Practice Address - Phone:407-988-8873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY351239164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty