Provider Demographics
NPI:1871301812
Name:PHENGMANIVANH, KAYLA (RPH)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:PHENGMANIVANH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2508
Mailing Address - Country:US
Mailing Address - Phone:559-286-7901
Mailing Address - Fax:
Practice Address - Street 1:785 N MEDICAL CENTER DR W STE 203
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6878
Practice Address - Country:US
Practice Address - Phone:559-387-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist