Provider Demographics
NPI:1093228926
Name:PHILAVONG-DANH, MONEMALA (NP-C)
Entity Type:Individual
Prefix:
First Name:MONEMALA
Middle Name:
Last Name:PHILAVONG-DANH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10590 TOWN CENTER DR STE 170
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0361
Mailing Address - Country:US
Mailing Address - Phone:909-483-0000
Mailing Address - Fax:
Practice Address - Street 1:330 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4823
Practice Address - Country:US
Practice Address - Phone:951-849-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF08170474363LF0000X
CANP95008033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily