=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871939009
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOKHA PHE NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2013
-----------------------------------------------------
Last Update Date | 05/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1333 CHESTNUT AVE
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90813-2944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-599-2153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1061 WALNUT AVE APT # 218
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90813-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-225-9880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 646268
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------