Provider Demographics
NPI:1164954061
Name:NGUYEN, BUUNGOC AMANDA KIM
Entity Type:Individual
Prefix:
First Name:BUUNGOC AMANDA
Middle Name:KIM
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20452 RODAX ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-1333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20452 RODAX ST
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-1333
Practice Address - Country:US
Practice Address - Phone:818-987-8915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program