Healthcare Provider Details

I. General information

NPI: 1053440065
Provider Name (Legal Business Name): LOAN VU MINH PHAM DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 10/23/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 PACIFIC HWY E STE C2
FIFE WA
98424-2638
US

IV. Provider business mailing address

3345 MICHELSON DR STE 100
IRVINE CA
92612-0693
US

V. Phone/Fax

Practice location:
  • Phone: 714-880-5065
  • Fax:
Mailing address:
  • Phone: 888-227-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-APRN-LIC-173734
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202101970NP-PP
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number16368
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61138359
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number1709
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: