=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780273250
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOUTNAKHON PHANDANOUVONG APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2021
-----------------------------------------------------
Last Update Date | 06/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 GRAND AVE
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72904-7028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-208-4601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5728 KIBLER RD
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-7576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-459-0046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 214525
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------