Healthcare Provider Details

I. General information

NPI: 1962013854
Provider Name (Legal Business Name): KATRINA MARIE NGUYEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 W VINE ST STE 105
LODI CA
95242-3731
US

IV. Provider business mailing address

7210 MURRAY DR
STOCKTON CA
95210-3339
US

V. Phone/Fax

Practice location:
  • Phone: 209-333-3121
  • Fax: 209-762-6808
Mailing address:
  • Phone: 209-373-2800
  • Fax: 209-762-6808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95015121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: