=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851022073
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKY PHAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2022
-----------------------------------------------------
Last Update Date | 08/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12351 PENTAGON ST
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92841-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-383-4670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4152 KATELLA AVE STE 201
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-6608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-598-0600
-----------------------------------------------------
Fax | 562-598-0678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 95021273
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------