Provider Demographics
NPI:1538321534
Name:PHOMVONGSA, DAVON
Entity Type:Individual
Prefix:
First Name:DAVON
Middle Name:
Last Name:PHOMVONGSA
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 1:12617 LINDO LN
Mailing Address - Street 2:UNIT C
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-4267
Mailing Address - Country:US
Mailing Address - Phone:619-851-8012
Mailing Address - Fax:
Practice Address - Street 1:2122 CORTE PLATA ESPUELA
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3184
Practice Address - Country:US
Practice Address - Phone:619-659-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN185979164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA92543753A65053Medicaid