Provider Demographics
NPI:1215083738
Name:GONG, AMANDA (LVN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2857 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611
Mailing Address - Country:US
Mailing Address - Phone:559-325-6518
Mailing Address - Fax:
Practice Address - Street 1:2857 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611
Practice Address - Country:US
Practice Address - Phone:559-325-6518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN214738164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS014610OtherCALIFORNIA MEDICAID
CARVN002950OtherPROGRAM