Provider Demographics
NPI:1053054361
Name:SOONTHORNPONG, KHWANTHIDA (NP)
Entity type:Individual
Prefix:
First Name:KHWANTHIDA
Middle Name:
Last Name:SOONTHORNPONG
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4599
Mailing Address - Country:US
Mailing Address - Phone:714-647-6092
Mailing Address - Fax:
Practice Address - Street 1:9388 LIGHTWAVE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1426
Practice Address - Country:US
Practice Address - Phone:858-541-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95235554163W00000X
CA95032334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse