Healthcare Provider Details

I. General information

NPI: 1053054361
Provider Name (Legal Business Name): KHWANTHIDA SOONTHORNPONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9388 LIGHTWAVE AVE
SAN DIEGO CA
92123-1426
US

IV. Provider business mailing address

405 W 5TH ST
SANTA ANA CA
92701-4599
US

V. Phone/Fax

Practice location:
  • Phone: 858-541-7710
  • Fax:
Mailing address:
  • Phone: 714-647-6092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95032334
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95235554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: