Healthcare Provider Details

I. General information

NPI: 1891614228
Provider Name (Legal Business Name): MS. PANASNAN WONGSUVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5152 FOUNTAIN AVE
LOS ANGELES CA
90029-1320
US

IV. Provider business mailing address

5152 FOUNTAIN AVE
LOS ANGELES CA
90029-1320
US

V. Phone/Fax

Practice location:
  • Phone: 818-793-3269
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number66215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: