Healthcare Provider Details

I. General information

NPI: 1417636689
Provider Name (Legal Business Name): KHIM LEANG LY SONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 S 1ST ST STE D
ALHAMBRA CA
91801-3790
US

IV. Provider business mailing address

328 S 1ST ST STE D
ALHAMBRA CA
91801-3790
US

V. Phone/Fax

Practice location:
  • Phone: 833-476-7377
  • Fax:
Mailing address:
  • Phone: 833-476-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95021730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: