Provider Demographics
NPI:1770332413
Name:PHOUANGMALAY, WASANA J (CST, CSFA)
Entity type:Individual
Prefix:
First Name:WASANA
Middle Name:J
Last Name:PHOUANGMALAY
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-4948
Mailing Address - Country:US
Mailing Address - Phone:404-435-3216
Mailing Address - Fax:
Practice Address - Street 1:137 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-4948
Practice Address - Country:US
Practice Address - Phone:404-435-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant