Provider Demographics
NPI:1548714678
Name:JIARAVANONT, PALERATH NATALIE (LAC)
Entity type:Individual
Prefix:MS
First Name:PALERATH
Middle Name:NATALIE
Last Name:JIARAVANONT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12924 DISCOVERY CRK
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2207
Mailing Address - Country:US
Mailing Address - Phone:646-729-6313
Mailing Address - Fax:
Practice Address - Street 1:13315 W WASHINGTON BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5169
Practice Address - Country:US
Practice Address - Phone:646-792-6313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14970171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist