Provider Demographics
NPI:1740692540
Name:UMOJA, DOMEVLO (LVN)
Entity type:Individual
Prefix:
First Name:DOMEVLO
Middle Name:
Last Name:UMOJA
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W CLINTON AVE UNIT 397
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4223
Mailing Address - Country:US
Mailing Address - Phone:559-264-7521
Mailing Address - Fax:559-860-0168
Practice Address - Street 1:2550 W CLINTON AVE BLDG W
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4206
Practice Address - Country:US
Practice Address - Phone:559-264-7521
Practice Address - Fax:559-860-0168
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 276219164X00000X
CAVN276219164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse