Provider Demographics
NPI:1194291245
Name:PHAM, VANNESSA (HAD)
Entity type:Individual
Prefix:
First Name:VANNESSA
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 GARDEN GROVE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-8234
Mailing Address - Country:US
Mailing Address - Phone:714-859-5732
Mailing Address - Fax:
Practice Address - Street 1:802 MAGNOLIA AVE STE 208
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3157
Practice Address - Country:US
Practice Address - Phone:951-736-1630
Practice Address - Fax:951-736-8964
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA8404237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty