Provider Demographics
NPI:1588932495
Name:PHOLSENA, THEPTHARA NUI
Entity type:Individual
Prefix:
First Name:THEPTHARA
Middle Name:NUI
Last Name:PHOLSENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NUI
Other - Middle Name:
Other - Last Name:PHOLSENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-3335
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:17707 W MAIN ST
Practice Address - Street 2:1ST FL
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1967
Practice Address - Country:US
Practice Address - Phone:360-282-3885
Practice Address - Fax:360-282-3886
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60248306363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health