Healthcare Provider Details

I. General information

NPI: 1851297337
Provider Name (Legal Business Name): CHUTIWAN N/A TANASAPPHAISAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2026
Last Update Date: 10/20/2026
Certification Date: 10/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

2525 E DATE PALM PASEO APT 3028
ONTARIO CA
91764-7629
US

V. Phone/Fax

Practice location:
  • Phone: 213-344-9236
  • Fax:
Mailing address:
  • Phone: 213-344-9236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95041548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: