MEDICARE: QUYNH NGOC PHUONG NGUYEN NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	1040222	TX
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1040222	TX

General Provider Information

NPI Number	:	1154194553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUYNH NGOC PHUONG NGUYEN NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	5900 BALCONES DR STE 23154
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78731-4257
Country	:	US
Telephone Number	:	972-886-8869
Fax Number	:

Provider Business Practice Location Address
First Line	:	5900 BALCONES DR STE 23154
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78731-4257
Country	:	US
Telephone Number	:	972-886-8869
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2023
Last Update Date	:	01/19/2026

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