Healthcare Provider Details

I. General information

NPI: 1174319552
Provider Name (Legal Business Name): MAI NICOLE LE PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE THI LE

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 NW 7TH ST
OKLAHOMA CITY OK
73102-2810
US

IV. Provider business mailing address

2712 SW 96TH CT
OKLAHOMA CITY OK
73159-6736
US

V. Phone/Fax

Practice location:
  • Phone: 405-413-4689
  • Fax:
Mailing address:
  • Phone: 918-360-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number218733
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: