Healthcare Provider Details

I. General information

NPI: 1649509134
Provider Name (Legal Business Name): CHANTHOL PEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 EAST AVENUE K
LANCASTER CA
93535-5938
US

IV. Provider business mailing address

2151 E PALMDALE BLVD SUITE
PALMDALE CA
93550-4037
US

V. Phone/Fax

Practice location:
  • Phone: 661-579-9760
  • Fax: 661-579-9765
Mailing address:
  • Phone: 661-942-2391
  • Fax: 661-575-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9232475
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: