Provider Demographics
NPI:1851756589
Name:NGUYEN, PHOMMALONE MONE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:PHOMMALONE
Middle Name:MONE
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:FNP
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:254-215-9722
Practice Address - Street 1:10815 RANCH ROAD 2222 BLDG 3A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78730-1159
Practice Address - Country:US
Practice Address - Phone:512-327-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129896363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX357490701Medicaid
TX486775YK73Medicare PIN