Provider Demographics
NPI:1821551508
Name:MWAENGO, JOHN LANGALI (RN)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LANGALI
Last Name:MWAENGO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9455 FOULKS RANCH DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4320
Mailing Address - Country:US
Mailing Address - Phone:951-322-9527
Mailing Address - Fax:
Practice Address - Street 1:9455 FOULKS RANCH DR
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-4320
Practice Address - Country:US
Practice Address - Phone:951-322-9527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT41074167G00000X
AZ290496163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF7755199OtherDRIVERS LICENSE