Provider Demographics
NPI:1053099630
Name:PHIMSIPRASOM, VONGSAVANH TED (RN)
Entity type:Individual
Prefix:
First Name:VONGSAVANH
Middle Name:TED
Last Name:PHIMSIPRASOM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11436 E PINE MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-7202
Mailing Address - Country:US
Mailing Address - Phone:316-992-7290
Mailing Address - Fax:316-469-0815
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-803-2356
Practice Address - Fax:316-469-0815
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS112882163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse