MEDICARE: PHAPHONE CHANTHACHONE AGACNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	1086858	TX

General Provider Information

NPI Number	:	1013626100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHAPHONE CHANTHACHONE AGACNP-BC

Provider Business Mailing Address
First Line	:	7845 HIGHTOWER DR
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-3402
Country	:	US
Telephone Number	:	214-529-6765
Fax Number	:

Provider Business Practice Location Address
First Line	:	7845 HIGHTOWER DR
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-3402
Country	:	US
Telephone Number	:	214-529-6765
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2022
Last Update Date	:	11/17/2022

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