Individual
CHITTADAPHONE PHOUTHAVONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RN
Contact information
Practice address
111 WESTFALL RD, ROCHESTER, NY 14620-4647
(585) 353-9305
Mailing address
111 WESTFALL RD, ROCHESTER, NY 14620-4647
(585) 353-9305
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
777030
NY
164W00000X
Licensed Practical Nurse
287928
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1952600330
—
NY
Enumeration date
03/24/2011
Last updated
08/19/2019
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