Healthcare Provider Details

I. General information

NPI: 1386294643
Provider Name (Legal Business Name): DIEP-KIMBERLY NGOC NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM NGOC NGUYEN

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 W LAKE LANSING RD STE 130
EAST LANSING MI
48823-1317
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 517-333-6692
  • Fax: 517-333-6705
Mailing address:
  • Phone: 630-575-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070028383
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501303012
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-034347
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: