Provider Demographics
NPI:1265984397
Name:WONGTHIPKONGKA, NISA (LAC)
Entity type:Individual
Prefix:MS
First Name:NISA
Middle Name:
Last Name:WONGTHIPKONGKA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 W FARWELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3695
Mailing Address - Country:US
Mailing Address - Phone:312-718-8080
Mailing Address - Fax:
Practice Address - Street 1:1650 W FARWELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-3695
Practice Address - Country:US
Practice Address - Phone:312-718-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001170171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist