Healthcare Provider Details

I. General information

NPI: 1962922088
Provider Name (Legal Business Name): NANCY PHAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 E 3900 S STE 340
SALT LAKE CITY UT
84124-1244
US

IV. Provider business mailing address

PO BOX 742382
ATLANTA GA
30374-2382
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-7479
  • Fax: 801-268-7622
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number12494827-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007201
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202211106NP-PP
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12494827-4405
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95129038
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: