Provider Demographics
NPI:1841838844
Name:MONGALI, LAURETTA
Entity type:Individual
Prefix:
First Name:LAURETTA
Middle Name:
Last Name:MONGALI
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 1:3880 WYNN RD APT 322M
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-2884
Mailing Address - Country:US
Mailing Address - Phone:309-740-8679
Mailing Address - Fax:
Practice Address - Street 1:2780 S JONES BLVD # 105B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5628
Practice Address - Country:US
Practice Address - Phone:702-333-1488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant