=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437012481
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVIS Q. PHAM PMHNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2025
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 SUNRISE HWY
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-264-4000
-----------------------------------------------------
Fax | 631-608-5261
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 SUNRISE HWY
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-264-4000
-----------------------------------------------------
Fax | 631-608-5261
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 406796
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------