Healthcare Provider Details

I. General information

NPI: 1154245181
Provider Name (Legal Business Name): PHOUTHAMYXAY WINNY CHANTHALALAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 N 66TH ST
MILWAUKEE WI
53213-2038
US

IV. Provider business mailing address

2204 N 66TH ST
MILWAUKEE WI
53213-2038
US

V. Phone/Fax

Practice location:
  • Phone: 920-471-8645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: