Healthcare Provider Details

I. General information

NPI: 1760269880
Provider Name (Legal Business Name): ANGELINA MAI HONG PHUOC VUONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17862 17TH ST STE 107
TUSTIN CA
92780-2170
US

IV. Provider business mailing address

17862 17TH ST STE 107
TUSTIN CA
92780-2170
US

V. Phone/Fax

Practice location:
  • Phone: 714-661-5390
  • Fax:
Mailing address:
  • Phone: 714-661-5390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number118054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: