Provider Demographics
NPI:1164167136
Name:PHETCHAMPHONE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PHETCHAMPHONE
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 1:1768 MITCHELL RD
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2156
Mailing Address - Country:US
Mailing Address - Phone:209-353-4838
Mailing Address - Fax:
Practice Address - Street 1:1768 MITCHELL RD
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-2156
Practice Address - Country:US
Practice Address - Phone:209-353-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA713585164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse