Provider Demographics
NPI:1063287837
Name:THIONGO, CAROLINE KEZIAH
Entity type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:KEZIAH
Last Name:THIONGO
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 1:21155 E DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-6763
Mailing Address - Country:US
Mailing Address - Phone:972-302-1431
Mailing Address - Fax:
Practice Address - Street 1:12360 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9320
Practice Address - Country:US
Practice Address - Phone:503-303-4000
Practice Address - Fax:503-344-4412
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ298740163WP0808X
OR10021621363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health