Healthcare Provider Details

I. General information

NPI: 1467055855
Provider Name (Legal Business Name): MRS. DICKEY WANGMO THUKHOTSONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 CARLSON BLVD
EL CERRITO CA
94530-3907
US

IV. Provider business mailing address

2410 HIGH SCHOOL AVE
CONCORD CA
94520-1829
US

V. Phone/Fax

Practice location:
  • Phone: 510-734-3560
  • Fax:
Mailing address:
  • Phone: 510-734-3560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95015915
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95080619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: