Provider Demographics
NPI:1609260173
Name:PHAM, LIEU
Entity Type:Individual
Prefix:
First Name:LIEU
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 1:31 EQUESTRIAN RD
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-8006
Mailing Address - Country:US
Mailing Address - Phone:609-829-3024
Mailing Address - Fax:
Practice Address - Street 1:700 TOWN BANK RD
Practice Address - Street 2:
Practice Address - City:NORTH CAPE MAY
Practice Address - State:NJ
Practice Address - Zip Code:08204-4411
Practice Address - Country:US
Practice Address - Phone:609-898-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00609800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NR15527300OtherREGISTERED NURSE
NJ26NJ00609800OtherADVANCE NURSE PRACTITIONER