Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | RN2270203 | MA |
NPI | 1073044616 |
---|---|
Provider Name | Miadette Pheng-Phal |
First Address | Lynn, MA 01901-1314 |
Second Address | Lynn, MA 01901-1314 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2017 |
Last Update Date | 24/03/2017 |