Healthcare Provider Details

I. General information

NPI: 1619278546
Provider Name (Legal Business Name): NICOLE MARIE VUONG LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 S KINNELOA AVE SUITE 100
PASADENA CA
91107-3853
US

IV. Provider business mailing address

36 S. KINNELOA AVE. SUITE 100
PASADENA CA
91107
US

V. Phone/Fax

Practice location:
  • Phone: 626-844-3033
  • Fax: 626-844-3039
Mailing address:
  • Phone: 626-844-3033
  • Fax: 626-844-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN252509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: