Provider Demographics
NPI:1952636136
Name:LE, SONG PHUONG DIEP (ARNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:SONG PHUONG
Middle Name:DIEP
Last Name:LE
Suffix:
Gender:M
Credentials:ARNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 RASPBERRY SPAR CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76005-1210
Mailing Address - Country:US
Mailing Address - Phone:713-876-3993
Mailing Address - Fax:866-861-2145
Practice Address - Street 1:4545 HERITAGE TRACE PKWY STE 1500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8938
Practice Address - Country:US
Practice Address - Phone:682-683-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2024-01-21
Deactivation Date:2020-04-11
Deactivation Code:
Reactivation Date:2020-04-29
Provider Licenses
StateLicense IDTaxonomies
FL11006612363LF0000X
TX1079265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily