Healthcare Provider Details

I. General information

NPI: 1083429369
Provider Name (Legal Business Name): MYDUNG PHAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/16/2025
Certification Date: 02/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6637 N 58TH DR APT 3
GLENDALE AZ
85301-3900
US

IV. Provider business mailing address

6637 N 58TH DR APT 3
GLENDALE AZ
85301-3900
US

V. Phone/Fax

Practice location:
  • Phone: 480-918-4775
  • Fax:
Mailing address:
  • Phone: 480-918-4775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: MYDUNG THI PHAN
Title or Position: REGISTERED NUTRIONIST
Credential: RDN
Phone: 480-918-4775