Healthcare Provider Details

I. General information

NPI: 1922696129
Provider Name (Legal Business Name): PHUONG LY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S ORANGE AVE STE 103
ORLANDO FL
32806-2946
US

IV. Provider business mailing address

1717 S ORANGE AVE STE 103
ORLANDO FL
32806-2946
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-3444
  • Fax: 321-843-1753
Mailing address:
  • Phone: 321-841-3444
  • Fax: 321-843-1753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116750
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: