MEDICARE: MRS. BOUNTHIENG S. OUANESISOUK RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WM0705X	Medical-Surgical Registered Nurse	200541699RN	OR

General Provider Information

NPI Number	:	1114194602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BOUNTHIENG S. OUANESISOUK RN

Provider Business Mailing Address
First Line	:	19313 GENTRY HIGHLANDS LN
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-7577
Country	:	US
Telephone Number	:	503-442-9573
Fax Number	:

Provider Business Practice Location Address
First Line	:	19313 GENTRY HIGHLANDS LN
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-7577
Country	:	US
Telephone Number	:	503-442-9573
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	05/13/2008

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