Provider Demographics
NPI:1295356343
Name:XAYAVONG, ROSA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:XAYAVONG
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 1:2643 ALBERT RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-4121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:592 RIO LINDO AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1817
Practice Address - Country:US
Practice Address - Phone:530-891-2775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA702660164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse