Provider Demographics
NPI:1740090224
Name:VONGVILAY, JOHNNY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:VONGVILAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18600 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-6723
Mailing Address - Country:US
Mailing Address - Phone:971-255-0658
Mailing Address - Fax:
Practice Address - Street 1:1600 N 20TH AVE STE A
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-3376
Practice Address - Country:US
Practice Address - Phone:509-537-3025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist