Provider Demographics
NPI:1982165940
Name:THUMMACHAROEN, TASSANIDA (APRN)
Entity Type:Individual
Prefix:
First Name:TASSANIDA
Middle Name:
Last Name:THUMMACHAROEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6429 NW 171ST ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4615
Mailing Address - Country:US
Mailing Address - Phone:305-788-7815
Mailing Address - Fax:
Practice Address - Street 1:6429 NW 171ST ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4615
Practice Address - Country:US
Practice Address - Phone:305-788-7815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-30
Last Update Date:2019-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF11180978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily