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General NPI Number Information
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NPI Number | 1437795333
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Entity Type | Individual
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Provider Name | MIKEY THANTERAPHONG
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Gender | Male
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Dates
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Enumeration Date | 11/26/2019
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Last Update Date | 09/25/2025
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Provider Practice Location Address
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Address Line | 2845 COCHRAN ST STE B
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City | SIMI VALLEY
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State | CA
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Zip | 93065-7905
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Country | US
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Telephone | 818-835-7355
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 336
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City | AGOURA HILLS
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State | CA
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Zip | 91376-0336
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Country | US
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Telephone | 818-835-7355
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 95013063
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License Number State | CA
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