Provider Demographics
NPI:1770896508
Name:WONGRAVEEKUL, SUCHEERA (NP)
Entity type:Individual
Prefix:
First Name:SUCHEERA
Middle Name:
Last Name:WONGRAVEEKUL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3509
Mailing Address - Country:US
Mailing Address - Phone:310-886-0869
Mailing Address - Fax:310-886-0870
Practice Address - Street 1:3625 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3509
Practice Address - Country:US
Practice Address - Phone:310-886-0869
Practice Address - Fax:310-886-0870
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA19918363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner