Provider Demographics
NPI:1740944263
Name:PHUNKASETWATTHANA, PAWINEE
Entity type:Individual
Prefix:
First Name:PAWINEE
Middle Name:
Last Name:PHUNKASETWATTHANA
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 1:922 FEDORA ST APT 5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-1436
Mailing Address - Country:US
Mailing Address - Phone:417-396-7051
Mailing Address - Fax:
Practice Address - Street 1:922 FEDORA ST APT 5
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-1436
Practice Address - Country:US
Practice Address - Phone:417-396-7051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-30
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist