Healthcare Provider Details

I. General information

NPI: 1952922395
Provider Name (Legal Business Name): JENNIFER HUYNH FANTROY NGUYEN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER HUYNH FONGSAMOUTH N.P.

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 N LITCHFIELD RD STE 125
GOODYEAR AZ
85395-1215
US

IV. Provider business mailing address

PO BOX 18892
BELFAST ME
04915-4083
US

V. Phone/Fax

Practice location:
  • Phone: 623-242-1231
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61088873
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRNP26394
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26394
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61087160
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: