MEDICARE: AMBERLY ANTANA INTHAVONG

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1710759832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBERLY ANTANA INTHAVONG

Provider Business Mailing Address
First Line	:	4222 DUNDEE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43227-3639
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4222 DUNDEE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43227-3639
Country	:	US
Telephone Number	:	614-584-8894
Fax Number	:

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

Provider Enumeration Date	:	10/23/2023
Last Update Date	:	04/02/2025

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Directions to “ AMBERLY ANTANA INTHAVONG ” Practice Location

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