Provider Demographics
NPI:1932960895
Name:PHAM, NICOLE KIEU KHANH (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KIEU KHANH
Last Name:PHAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 TIMBERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6619
Mailing Address - Country:US
Mailing Address - Phone:214-770-2842
Mailing Address - Fax:
Practice Address - Street 1:317 TIMBERLEAF DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6619
Practice Address - Country:US
Practice Address - Phone:214-770-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist