Provider Demographics
NPI:1215698600
Name:NGUYEN, KATIE P
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:P
Last Name:NGUYEN
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 1:9101 GETTYSBURG DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-3413
Mailing Address - Country:US
Mailing Address - Phone:714-801-9948
Mailing Address - Fax:
Practice Address - Street 1:27220 HEATHER RIDGE RD
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-3418
Practice Address - Country:US
Practice Address - Phone:714-801-9948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH55487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0577873Medicaid