Provider Demographics
NPI:1023285970
Name:AMKHAMAVONG, VICKIE VIENKHONG
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:VIENKHONG
Last Name:AMKHAMAVONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 N. PERSHING AVE CL
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207
Mailing Address - Country:US
Mailing Address - Phone:209-403-6789
Mailing Address - Fax:
Practice Address - Street 1:4410 N PERSHING AVE STE C1
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6960
Practice Address - Country:US
Practice Address - Phone:209-323-5338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker