Provider Demographics
NPI:1346819018
Name:MENTION, DEOGRACIA BANO
Entity Type:Individual
Prefix:
First Name:DEOGRACIA
Middle Name:BANO
Last Name:MENTION
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 1:7240 E SOUTHGATE DR STE G
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2627
Mailing Address - Country:US
Mailing Address - Phone:916-391-4293
Mailing Address - Fax:
Practice Address - Street 1:165 SPARROW DR
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-2446
Practice Address - Country:US
Practice Address - Phone:916-214-9281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN242497164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse