Provider Demographics
NPI:1104461847
Name:GONGORA, DANIEL A (LVN)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:GONGORA
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:SMITH RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95567-0554
Mailing Address - Country:US
Mailing Address - Phone:707-954-5940
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA169269164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse