Healthcare Provider Details

I. General information

NPI: 1265919518
Provider Name (Legal Business Name): NOU VANG DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 E MEDICINE LAKE BLVD
PLYMOUTH MN
55441-2307
US

IV. Provider business mailing address

1415 JESSAMINE AVE W APT 205
SAINT PAUL MN
55108-2634
US

V. Phone/Fax

Practice location:
  • Phone: 763-559-3123
  • Fax:
Mailing address:
  • Phone: 715-450-5293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11217
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: