Phonmany Phengphavong

Primary specialty

Licensed Vocational NurseTaxonomy code 164X00000X

License

287603 Issued in CA

Practice address

1688 N Perris Blvd
Perris, CA 92571-4709

Phone

(951) 443-2200

NPI assigned

Apr 3, 2020

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1585872000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1585872000000",
    "number": "1043849847",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2982 BAUTISTA ST",
            "city": "RIVERSIDE",
            "state": "CA",
            "postal_code": "925064293",
            "telephone_number": "951-224-2620"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1688 N PERRIS BLVD",
            "city": "PERRIS",
            "state": "CA",
            "postal_code": "925714709",
            "telephone_number": "951-443-2200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PHENGPHAVONG",
        "first_name": "PHONMANY",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-04-03",
        "last_updated": "2020-04-03",
        "certification_date": "2020-04-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "164X00000X",
            "taxonomy_group": "",
            "desc": "Licensed Vocational Nurse",
            "state": "CA",
            "license": "287603",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "OTHER",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Perris Valley Medical Group, Inc.
• Perris Valley Physicians Associates, a Medical Corp.
• Perris Valley Recovery Program, Inc.
• Alicia Perry
• Perris Peterson
• Kakesha Phillips
• Pico de Loro, Incorporated
• Guillermo Pina, AMFT140631
• Trena Renee Pleasant, RN
• Nicole Lynn Plonte

• Licensed Vocational Nurse in Perris, CA
• Providers in Perris, CA by specialty
• Licensed Vocational Nurse in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 3, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.