Provider Demographics
NPI:1295454502
Name:SIRIHEKAPHONG, SUPINDA
Entity type:Individual
Prefix:
First Name:SUPINDA
Middle Name:
Last Name:SIRIHEKAPHONG
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 1:6259 ADOBE RD # A-1
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-2649
Mailing Address - Country:US
Mailing Address - Phone:760-206-6467
Mailing Address - Fax:
Practice Address - Street 1:6259 ADOBE RD # A-1
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2649
Practice Address - Country:US
Practice Address - Phone:760-206-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95831225700000X
IL13013374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist