Provider Demographics
NPI:1437694627
Name:PHAM, TRACY (RN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9451 INDIANAPOLIS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-5955
Mailing Address - Country:US
Mailing Address - Phone:714-593-9630
Mailing Address - Fax:714-964-5321
Practice Address - Street 1:9451 INDIANAPOLIS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-5955
Practice Address - Country:US
Practice Address - Phone:714-593-9630
Practice Address - Fax:714-964-5321
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95041403163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse