Provider Demographics
NPI:1013342120
Name:MOUANOUTOUA, IA ONG (RN)
Entity Type:Individual
Prefix:
First Name:IA
Middle Name:ONG
Last Name:MOUANOUTOUA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:IA
Other - Middle Name:ONG
Other - Last Name:VANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4411 E. KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA - CALIFORNIA
Mailing Address - Zip Code:93702
Mailing Address - Country:UM
Mailing Address - Phone:651-352-2767
Mailing Address - Fax:
Practice Address - Street 1:4411 E. KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA - CALIFORNIA
Practice Address - Zip Code:93702
Practice Address - Country:UM
Practice Address - Phone:651-352-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-08
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN219164-5163W00000X
CA837680163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse