Healthcare Provider Details

I. General information

NPI: 1679242713
Provider Name (Legal Business Name): MINHTAM T NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2021
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 MORTON ST
MATTAPAN MA
02126-2834
US

IV. Provider business mailing address

488 FERRY ST
EVERETT MA
02149-5656
US

V. Phone/Fax

Practice location:
  • Phone: 617-533-2300
  • Fax:
Mailing address:
  • Phone: 617-642-6490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN2345797
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: