Healthcare Provider Details

I. General information

NPI: 1982162970
Provider Name (Legal Business Name): MYLA THONG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 GILBERT ST
OAKLAND CA
94611-4657
US

IV. Provider business mailing address

PO BOX 511250
LOS ANGELES CA
90051-7805
US

V. Phone/Fax

Practice location:
  • Phone: 510-929-1400
  • Fax: 510-929-1414
Mailing address:
  • Phone: 510-929-1400
  • Fax: 510-929-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95011125
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: