Provider Demographics
NPI:1417477860
Name:PONGPUNGAM, JENNIFER (RN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:PONGPUNGAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 E AVENUE I
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-1916
Mailing Address - Country:US
Mailing Address - Phone:661-471-4360
Mailing Address - Fax:
Practice Address - Street 1:335 E AVENUE I STE 24
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-1916
Practice Address - Country:US
Practice Address - Phone:661-471-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA542305163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care