Provider Demographics
NPI:1780273250
Name:PHANDANOUVONG, SOUTNAKHON (APRN)
Entity type:Individual
Prefix:
First Name:SOUTNAKHON
Middle Name:
Last Name:PHANDANOUVONG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5728 KIBLER RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-7576
Mailing Address - Country:US
Mailing Address - Phone:479-459-0046
Mailing Address - Fax:
Practice Address - Street 1:4300 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-7028
Practice Address - Country:US
Practice Address - Phone:479-208-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR214525363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily