Nicksic, Souphaphone Bounmythavong

Nicksic, Souphaphone Bounmythavong is an individual health care provider with primary practice located at 1425 N Randall Rd , Elgin IL 60123-2300. She recently has only one registered license in Physician Assistants & Advanced Practice Nursing Providers / Nurse Anesthetist, Certified Registered, which is considered as her primary health care specialty. Nicksic, Souphaphone Bounmythavong can be contacted via phone (224) 783-1065.

Contact Information

Primary practice address
1425 N Randall Rd Elgin IL 60123-2300
Phone: (224) 783-1065
Fax: (224) 783-2852
Website:
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Health care specialties

SpecialtyCodeLicense #State
Physician Assistants & Advanced Practice Nursing Providers / Nurse Anesthetist, Certified Registered 367500000X 28181986A Indiana
Physician Assistants & Advanced Practice Nursing Providers / Nurse Anesthetist, Certified Registered 367500000X 209008677 Illinois

Profile Details

NPI number 1740425701
LBN Legal business name Nicksic, Souphaphone Bounmythavong
Credentials Certified Registered Nurse Anesthetist (CRNA)
Entity Individual
Sole proprietor 1 No
Enumeration date Dec 4th, 2008
Last updated Aug 30th, 2023 - about 3 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1740425701 NPPES
Indiana Other 000000610221 ANTHEM PROVIDER NUMBER
Indiana MEDICAID 200949460 ANTHEM PROVIDER NUMBER

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