Healthcare Provider Details

I. General information

NPI: 1699312231
Provider Name (Legal Business Name): PRISCILLA NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17122 BEACH BLVD STE 104
HUNTINGTON BEACH CA
92647-5992
US

IV. Provider business mailing address

14182 LAKE ST
GARDEN GROVE CA
92843-4809
US

V. Phone/Fax

Practice location:
  • Phone: 714-964-4448
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA49310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: