Provider Demographics
NPI:1396382388
Name:CONVERSE PHIMMASONE, MYHASA LINN (LVN)
Entity Type:Individual
Prefix:
First Name:MYHASA
Middle Name:LINN
Last Name:CONVERSE PHIMMASONE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:MYH
Other - Middle Name:
Other - Last Name:PHIMMASONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:892 27TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-1444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:892 27TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1444
Practice Address - Country:US
Practice Address - Phone:619-575-4687
Practice Address - Fax:619-575-1215
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA703270164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse