Provider Demographics
NPI:1104425834
Name:PHAM, NICOLE NHU LAN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:NHU LAN
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 1:3714 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-3243
Mailing Address - Country:US
Mailing Address - Phone:832-744-1837
Mailing Address - Fax:
Practice Address - Street 1:13615 BELLAIRE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-1714
Practice Address - Country:US
Practice Address - Phone:281-933-3446
Practice Address - Fax:281-933-6865
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9959T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist