MEDICARE: MRS. DARLENE MY PHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1568063725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DARLENE MY PHAN

Provider Business Mailing Address
First Line	:	26460 SUMMIT CIR
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91350-2991
Country	:	US
Telephone Number	:	661-254-6630
Fax Number	:

Provider Business Practice Location Address
First Line	:	661 CLEARWATER CREEK DR
Second Line	:
City	:	NEWBURY PARK
State	:	CA
Zip	:	91320-4976
Country	:	US
Telephone Number	:	805-405-8060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2020
Last Update Date	:	11/04/2020

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