Provider Demographics
NPI:1649754367
Name:DECENA, VINAI PONGBANDITH (FNP, DNP)
Entity Type:Individual
Prefix:DR
First Name:VINAI
Middle Name:PONGBANDITH
Last Name:DECENA
Suffix:
Gender:F
Credentials:FNP, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3683 SKEENA AVE
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-7016
Mailing Address - Country:US
Mailing Address - Phone:209-541-7209
Mailing Address - Fax:
Practice Address - Street 1:1111 E TUOLUMNE RD
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-1541
Practice Address - Country:US
Practice Address - Phone:209-632-7577
Practice Address - Fax:209-669-9067
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009808363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty