Healthcare Provider Details

I. General information

NPI: 1952553539
Provider Name (Legal Business Name): KATHY PHAM TRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 W LAKESIDE PL APT 1507
CHICAGO IL
60640-5175
US

IV. Provider business mailing address

920 W LAKESIDE PL APT 1507
CHICAGO IL
60640-5175
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-1104
  • Fax:
Mailing address:
  • Phone: 773-769-1104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049144416
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: