Provider Demographics
NPI:1902540602
Name:VANNOY, LESLEY SIHAVONG
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:SIHAVONG
Last Name:VANNOY
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 1:7056 ARCHIBALD AVE # 102-322
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-8713
Mailing Address - Country:US
Mailing Address - Phone:951-847-5476
Mailing Address - Fax:
Practice Address - Street 1:13731 DELLBROOK ST
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-5521
Practice Address - Country:US
Practice Address - Phone:951-847-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home