Healthcare Provider Details

I. General information

NPI: 1083178099
Provider Name (Legal Business Name): MIMI HOANG PHAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 06/12/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S MAPLE AVE STE 200
FALLS CHURCH VA
22046-4243
US

IV. Provider business mailing address

250 OAK STREET
ROSWELL GA
30075
US

V. Phone/Fax

Practice location:
  • Phone: 703-532-5436
  • Fax: 703-532-3232
Mailing address:
  • Phone: 770-817-6070
  • Fax: 770-643-1858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024176132
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: