Provider Demographics
NPI:1023876398
Name:INTHAVONG, HALEIGH
Entity type:Individual
Prefix:
First Name:HALEIGH
Middle Name:
Last Name:INTHAVONG
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 1:1619 CHERRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-4203
Mailing Address - Country:US
Mailing Address - Phone:832-660-8686
Mailing Address - Fax:
Practice Address - Street 1:925 CITY CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2981
Practice Address - Country:US
Practice Address - Phone:936-202-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program