Healthcare Provider Details

I. General information

NPI: 1700571395
Provider Name (Legal Business Name): KIM AN PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BOSTON AVE STE 100
ALTAMONTE SPRINGS FL
32701-4712
US

IV. Provider business mailing address

106 BOSTON AVE STE 100
ALTAMONTE SPRINGS FL
32701-4712
US

V. Phone/Fax

Practice location:
  • Phone: 800-827-7546
  • Fax: 407-499-3665
Mailing address:
  • Phone: 800-827-7546
  • Fax: 407-499-3665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9535823
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number5018197
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5018197
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: