Provider Demographics
NPI:1811452030
Name:DUNGAN, VIVIAN SHEILA
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:SHEILA
Last Name:DUNGAN
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 1:32237 AGUA DULCE RD
Mailing Address - Street 2:
Mailing Address - City:AGUA DULCE
Mailing Address - State:CA
Mailing Address - Zip Code:91390
Mailing Address - Country:US
Mailing Address - Phone:818-371-8313
Mailing Address - Fax:
Practice Address - Street 1:32237 AGUA DULCE RD
Practice Address - Street 2:
Practice Address - City:AGUA DULCE
Practice Address - State:CA
Practice Address - Zip Code:91390
Practice Address - Country:US
Practice Address - Phone:818-371-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA358986364SP0810X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA358986OtherLICENSE NUMBER
358986OtherLICENSE NUMBER