Provider Demographics
NPI:1346734399
Name:DE HART, SONNY DE WAYNE (LVN)
Entity Type:Individual
Prefix:MR
First Name:SONNY
Middle Name:DE WAYNE
Last Name:DE HART
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 JUSTIN AVE APT D
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2927
Mailing Address - Country:US
Mailing Address - Phone:818-929-0932
Mailing Address - Fax:
Practice Address - Street 1:225 JUSTIN AVE APT D
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2927
Practice Address - Country:US
Practice Address - Phone:818-929-0932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN198057164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse