Provider Demographics
NPI:1740958487
Name:PHAM, MIMI NGUYEN
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:NGUYEN
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 1:12121 DITMORE DR
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-3333
Mailing Address - Country:US
Mailing Address - Phone:714-837-2623
Mailing Address - Fax:
Practice Address - Street 1:30 HUNTER LN
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2400
Practice Address - Country:US
Practice Address - Phone:800-748-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95228293163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical