Provider Demographics
NPI:1912655804
Name:PHAN, MYLINH (NP)
Entity type:Individual
Prefix:
First Name:MYLINH
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MYLINH
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:626-256-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP18379363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty