Provider Demographics
NPI:1609413830
Name:PHAM, MINHANH TRINH (DPT)
Entity Type:Individual
Prefix:
First Name:MINHANH
Middle Name:TRINH
Last Name:PHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:904-261-4414
Mailing Address - Fax:904-261-4614
Practice Address - Street 1:463646 STATE ROAD 200 STE 4
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-0303
Practice Address - Country:US
Practice Address - Phone:904-261-4414
Practice Address - Fax:904-261-4614
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9983225100000X
FLPT36205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist