Provider Demographics
NPI:1154190460
Name:PHOMMA, PHAWADEE DEE
Entity type:Individual
Prefix:
First Name:PHAWADEE
Middle Name:DEE
Last Name:PHOMMA
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 1:3419 S 203RD ST
Mailing Address - Street 2:
Mailing Address - City:SEATAC
Mailing Address - State:WA
Mailing Address - Zip Code:98198-5755
Mailing Address - Country:US
Mailing Address - Phone:206-889-7769
Mailing Address - Fax:
Practice Address - Street 1:3419 S 203RD ST
Practice Address - Street 2:
Practice Address - City:SEATAC
Practice Address - State:WA
Practice Address - Zip Code:98198-5755
Practice Address - Country:US
Practice Address - Phone:206-889-7769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANC60903719376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide