Provider Demographics
NPI:1952922395
Name:NGUYEN, JENNIFER HUYNH FANTROY (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HUYNH FANTROY
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:HUYNH
Other - Last Name:FONGSAMOUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3805 E BELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3805 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2105
Practice Address - Country:US
Practice Address - Phone:602-867-8644
Practice Address - Fax:602-864-3786
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRNP26394363LF0000X
WARN61087160163W00000X
AZ26394163W00000X
WAAP61088873363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1952922395Medicaid