Healthcare Provider Details

I. General information

NPI: 1265574461
Provider Name (Legal Business Name): VANPRASEUTH FONGNALY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 G RD
GRAND JUNCTION CO
81505-9641
US

IV. Provider business mailing address

PO BOX 1727
GRAND JUNCTION CO
81502-1727
US

V. Phone/Fax

Practice location:
  • Phone: 970-242-0920
  • Fax: 970-257-6251
Mailing address:
  • Phone: 970-257-6200
  • Fax: 970-263-2691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberCDRH.0068942
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number3724
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2014025191
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD0068983
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: