Provider Demographics
NPI:1326324393
Name:PHAM, KAYLA
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:
Last Name:PHAM
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 1:4640 CHAMPLAIN DR
Mailing Address - Street 2:SUITE 113
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-4714
Mailing Address - Country:US
Mailing Address - Phone:402-304-7564
Mailing Address - Fax:
Practice Address - Street 1:4640 CHAMPLAIN DR
Practice Address - Street 2:SUITE 113
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-4714
Practice Address - Country:US
Practice Address - Phone:402-304-7564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-22
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist