Provider Demographics
NPI:1962922088
Name:PHAM, NANCY (NP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742382
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 E 3900 S STE 340
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1244
Practice Address - Country:US
Practice Address - Phone:801-268-7479
Practice Address - Fax:801-268-7622
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95129038163W00000X
UT12494827-4405363L00000X, 363LF0000X
CA95007201363LF0000X
OR202211106NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner