Provider Demographics
NPI:1467088666
Name:LE, VIVIAN DANG
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:DANG
Last Name:LE
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 1:12931 DUNGAN LN
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5709
Mailing Address - Country:US
Mailing Address - Phone:714-326-3539
Mailing Address - Fax:
Practice Address - Street 1:10459 MOUNTAIN VIEW AVE STE F
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2033
Practice Address - Country:US
Practice Address - Phone:909-478-7651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013834363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner