Provider Demographics
NPI:1639444011
Name:PHAM, KIM
Entity Type:Individual
Prefix:
First Name:KIM
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 1:1704 SIR WILLIAM OSLER DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3003
Mailing Address - Country:US
Mailing Address - Phone:757-481-4383
Mailing Address - Fax:757-481-4611
Practice Address - Street 1:1704 SIR WILLIAM OSLER DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3003
Practice Address - Country:US
Practice Address - Phone:757-481-4383
Practice Address - Fax:757-481-4611
Is Sole Proprietor?:No
Enumeration Date:2012-03-18
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001187568163W00000X
VA0024169934363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse