Provider Demographics
NPI:1104448919
Name:KEODOUANGDY, THAILA
Entity type:Individual
Prefix:
First Name:THAILA
Middle Name:
Last Name:KEODOUANGDY
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:PO BOX 2867
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36652-2867
Mailing Address - Country:US
Mailing Address - Phone:251-690-8158
Mailing Address - Fax:
Practice Address - Street 1:19250 N MOBILE ST
Practice Address - Street 2:
Practice Address - City:CITRONELLE
Practice Address - State:AL
Practice Address - Zip Code:36522-2122
Practice Address - Country:US
Practice Address - Phone:251-866-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-136625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL261555Medicaid