Healthcare Provider Details

I. General information

NPI: 1972757052
Provider Name (Legal Business Name): MRS. PHUONG HUYNH NAKAMURA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2008
Last Update Date: 11/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

1452 N CHELSEA AVE
PALATINE IL
60067-2482
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-6137
  • Fax:
Mailing address:
  • Phone: 847-477-3624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number164.003794
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: