Provider Demographics
NPI:1427208263
Name:PHAN, NUONG AI (LICAC)
Entity type:Individual
Prefix:
First Name:NUONG
Middle Name:AI
Last Name:PHAN
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 CABOT ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3503
Mailing Address - Country:US
Mailing Address - Phone:781-354-6065
Mailing Address - Fax:
Practice Address - Street 1:990 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-1314
Practice Address - Country:US
Practice Address - Phone:781-354-6065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229947171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist