Provider Demographics
NPI:1346875531
Name:OUPRAVANH, PHOUANGMALY MIMI (DNP)
Entity Type:Individual
Prefix:
First Name:PHOUANGMALY
Middle Name:MIMI
Last Name:OUPRAVANH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 FARNUM ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:MA
Mailing Address - Zip Code:01504-2224
Mailing Address - Country:US
Mailing Address - Phone:401-692-1516
Mailing Address - Fax:
Practice Address - Street 1:42 CAPE RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3292
Practice Address - Country:US
Practice Address - Phone:800-853-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-08
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2338222163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse