Healthcare Provider Details

I. General information

NPI: 1215591417
Provider Name (Legal Business Name): PHUONG K. NGUYEN FAMILY NURSE PRACTIT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 W. PETERSON
CHICAGO IL
60659
US

IV. Provider business mailing address

2424 W. PETERSON AVE
CHICAGO IL
60659-3204
US

V. Phone/Fax

Practice location:
  • Phone: 773-761-0300
  • Fax: 773-761-0008
Mailing address:
  • Phone: 773-761-0011
  • Fax: 713-761-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.019131
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: