Healthcare Provider Details

I. General information

NPI: 1033748967
Provider Name (Legal Business Name): TANYA AM NANONGKHAI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 KING ST
CHARLESTON SC
29403-3708
US

IV. Provider business mailing address

125 DOUGHTY ST STE 530 MSC 917
CHARLESTON SC
29403-5744
US

V. Phone/Fax

Practice location:
  • Phone: 843-985-4473
  • Fax:
Mailing address:
  • Phone: 843-792-0269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number90003
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD61446233
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: