Healthcare Provider Details

I. General information

NPI: 1649967183
Provider Name (Legal Business Name): DOMINIQUE THUY NGUYEN R.T. (R)(M) ARRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 SYCAMORE DR
SIMI VALLEY CA
93065-1502
US

IV. Provider business mailing address

2836 JADESTONE AVE
SIMI VALLEY CA
93063-2148
US

V. Phone/Fax

Practice location:
  • Phone: 805-955-8150
  • Fax:
Mailing address:
  • Phone: 805-813-2463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License NumberRHM00085698
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: