Provider Demographics
NPI:1538860754
Name:PHAM, VIVIAN T (FNP-BC)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:T
Last Name:PHAM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 W GARVEY AVE S STE 240
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2655
Mailing Address - Country:US
Mailing Address - Phone:310-294-9027
Mailing Address - Fax:
Practice Address - Street 1:1900 W GARVEY AVE S STE 240
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2655
Practice Address - Country:US
Practice Address - Phone:310-294-9027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024496363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty