Provider Demographics
NPI:1851624571
Name:MGONJA, LILLIAN GRAY (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:LILLIAN
Middle Name:GRAY
Last Name:MGONJA
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MISS
Other - First Name:LILLIAN
Other - Middle Name:JOHN
Other - Last Name:MMARI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:623 S. LONG BEACH BLVD
Mailing Address - Street 2:SUITE A & B
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90221
Mailing Address - Country:US
Mailing Address - Phone:562-233-7970
Mailing Address - Fax:562-283-1000
Practice Address - Street 1:623 S. LONG BEACH BLVD
Practice Address - Street 2:SUITE A/B
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221
Practice Address - Country:US
Practice Address - Phone:310-637-0341
Practice Address - Fax:310-637-0341
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA581333163WA0400X
CA581433163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA581433OtherRN LICENSE
CA581433OtherREGISTERD NURSE