Provider Demographics
NPI:1497573067
Name:NGUYEN, LY KHANH
Entity type:Individual
Prefix:
First Name:LY
Middle Name:KHANH
Last Name:NGUYEN
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 1:404 CAMINO DEL RIO S STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3586
Mailing Address - Country:US
Mailing Address - Phone:800-316-6314
Mailing Address - Fax:
Practice Address - Street 1:188 QUINCY AVE UNIT B2
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-6774
Practice Address - Country:US
Practice Address - Phone:857-381-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-11-01
Deactivation Date:2024-10-15
Deactivation Code:
Reactivation Date:2024-11-01
Provider Licenses
StateLicense IDTaxonomies
MAR2344751163WM0705X
390200000X
MARN2344751363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program