Provider Demographics
NPI:1679225924
Name:PHANDANOUVONG, VONGPHONE D
Entity Type:Individual
Prefix:
First Name:VONGPHONE
Middle Name:D
Last Name:PHANDANOUVONG
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 1:727 ARROYO SECO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-7835
Mailing Address - Country:US
Mailing Address - Phone:619-699-9743
Mailing Address - Fax:
Practice Address - Street 1:30 HUNTER LANE
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011
Practice Address - Country:US
Practice Address - Phone:800-748-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95262784163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse