Provider Demographics
NPI:1962034199
Name:VONGPHOE, JI EUN
Entity Type:Individual
Prefix:
First Name:JI EUN
Middle Name:
Last Name:VONGPHOE
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 1:12341 ALAMO DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2290
Mailing Address - Country:US
Mailing Address - Phone:323-829-5485
Mailing Address - Fax:
Practice Address - Street 1:12341 ALAMO DR
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-2290
Practice Address - Country:US
Practice Address - Phone:323-829-5485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95010302363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care