Individual
SOUPHAPHONE BOUNMYTHAVONG NICKSIC
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
1425 N RANDALL RD, ELGIN, IL 60123-2300
(224) 783-1065
(224) 783-2852
Mailing address
29373 NETWORK PL, CHICAGO, IL 60673-1293
(847) 390-5900
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
209008677
IL
367500000X
Certified Registered Nurse Anesthetist
28181986A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000610221
ANTHEM PROVIDER NUMBER
IN
05
—
200949460
—
IN
Enumeration date
12/04/2008
Last updated
08/30/2023
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