Provider Demographics
NPI:1083178099
Name:PHAN, MIMI HOANG (FNP)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:HOANG
Last Name:PHAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S MAPLE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4243
Mailing Address - Country:US
Mailing Address - Phone:703-532-5436
Mailing Address - Fax:703-532-3232
Practice Address - Street 1:400 S MAPLE AVE STE 200
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4243
Practice Address - Country:US
Practice Address - Phone:703-532-5436
Practice Address - Fax:703-532-3232
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176132363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily