Provider Demographics
NPI:1528433430
Name:WALTHER, KONGKEO THIKY (ANP)
Entity type:Individual
Prefix:MRS
First Name:KONGKEO
Middle Name:THIKY
Last Name:WALTHER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:KONGKEO
Other - Middle Name:THIKY
Other - Last Name:VORACHACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776874
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6874
Mailing Address - Country:US
Mailing Address - Phone:314-291-7997
Mailing Address - Fax:314-739-1471
Practice Address - Street 1:12774 BOENKER LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2436
Practice Address - Country:US
Practice Address - Phone:314-291-7997
Practice Address - Fax:314-739-1471
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015040094363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420030952Medicaid
ILENROLLEDMedicaid