Provider Demographics
NPI:1043849847
Name:PHENGPHAVONG, PHONMANY
Entity Type:Individual
Prefix:
First Name:PHONMANY
Middle Name:
Last Name:PHENGPHAVONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2982 BAUTISTA ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4293
Mailing Address - Country:US
Mailing Address - Phone:951-224-2620
Mailing Address - Fax:
Practice Address - Street 1:1688 N PERRIS BLVD
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-4709
Practice Address - Country:US
Practice Address - Phone:951-443-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA287603164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOTHERMedicaid