Healthcare Provider Details

I. General information

NPI: 1609540319
Provider Name (Legal Business Name): THENETHONG SYBANGONE CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 09/11/2025
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 WORTH AVE
LOGANVILLE GA
30052-3660
US

IV. Provider business mailing address

2420 WORTH AVE
LOGANVILLE GA
30052-3660
US

V. Phone/Fax

Practice location:
  • Phone: 727-482-6866
  • Fax:
Mailing address:
  • Phone: 727-482-6866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: