Provider Demographics
NPI:1700200664
Name:PHAM, PHUONG DAOLE (PMHNP)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:DAOLE
Last Name:PHAM
Suffix:
Gender:F
Credentials:PMHNP
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 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:11770 BERNARDO PLAZA CT STE 370
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2426
Practice Address - Country:US
Practice Address - Phone:858-673-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95019215363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health