Healthcare Provider Details

I. General information

NPI: 1215533724
Provider Name (Legal Business Name): ANNIE NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date: 07/16/2022
Reactivation Date: 01/25/2023

III. Provider practice location address

3660 W BETHANY HOME RD STE B
PHOENIX AZ
85019-1953
US

IV. Provider business mailing address

4384 N 78TH ST APT 708
SCOTTSDALE AZ
85251-3745
US

V. Phone/Fax

Practice location:
  • Phone: 602-626-8851
  • Fax:
Mailing address:
  • Phone: 225-270-7210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA13949
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number011520390
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: