Provider Demographics
NPI:1518594084
Name:USONGO, MILDRED A (RN)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:A
Last Name:USONGO
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 1:9200 MILLIKEN AVE APT 5314
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8507
Mailing Address - Country:US
Mailing Address - Phone:818-257-3264
Mailing Address - Fax:
Practice Address - Street 1:LSC BEHAVIORAL HEALTH
Practice Address - Street 2:8300 UTICA AVE SUIT 310
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-9377
Practice Address - Country:US
Practice Address - Phone:909-906-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027844363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health