Healthcare Provider Details

I. General information

NPI: 1346233954
Provider Name (Legal Business Name): SHANNON PHUONG NGUYEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12107 BEACH BLVD
STANTON CA
90680-3706
US

IV. Provider business mailing address

12107 BEACH BLVD
STANTON CA
90680-3706
US

V. Phone/Fax

Practice location:
  • Phone: 714-373-5201
  • Fax: 714-373-5201
Mailing address:
  • Phone: 714-373-5201
  • Fax: 714-373-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12487T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: