Individual
DR. JOHN S INTHAVONGSA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DNP RN AGACNP-BC
Contact information
Practice address
4201 SAINT ANTOINE ST, DETROIT, MI 48201-2153
(313) 745-3000
(313) 745-4707
Mailing address
454 W ALEXANDRINE ST APT 18, DETROIT, MI 48201-1787
(347) 963-1896
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
4704309696
MI
363LA2100X
Acute Care Nurse Practitioner
Primary
4704309696
MI
Other
Enumeration date
05/17/2019
Last updated
06/04/2021
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